Crystal Clear: What Availity's Founding Story Teaches About Price Transparency

Patients increasingly expect to know what their care will cost before treatment begins. Getting them that information, however, depends on systems that were never designed to share it.

In the latest episode of Crystal Clear With Carol Skenes, a podcast series produced with The American Journal of Managed Care^®'s Managed Care Cast, host Carol Skenes, chief of staff and principal regulatory strategist at Turquoise Health, talked with Julie Klapstein about how technology, standardization, regulation, and cooperation can close those gaps. Klapstein was the founding CEO of Availity, leading the company from 2001 to 2012. She has more than 35 years of experience in health care IT and serves on several boards, including those of Claritev, Amedisys, and Omada Health.

Building Real-Time Payer-Provider Connections

Klapstein joined Availity in 2001 as its first employee, before the company had a name. The idea was to use the internet to connect payers and providers, starting in Florida with Blue Cross Blue Shield of Florida and Humana. The team believed it needed enough market participation to change how provider offices worked. That meant replacing batch processing and phone calls with real-time transactions for eligibility, benefits, claims status, and referrals.

Klapstein said speed and consistency determined whether providers would adopt the platform. Responses had to arrive in under 5 seconds, and information had to look the same no matter which payer it came from. That required payers to accept a neutral, shared portal instead of separate branded ones.

Infrastructure was also a barrier. Many practices had poor connectivity, so Availity installed high-speed modems in provider offices at no charge while it worked to expand beyond Florida.

Parallels to Price Transparency

Klapstein compared those early obstacles to today's push for upfront health care prices. Patients need estimates, but negotiated rates can be hard to access, and billing may be split among facilities and independent specialists. Accurate estimates also depend on translating services into the correct medical codes and accounting for deductibles.

She said common standards and regulations can help align that information, pointing to HIPAA transaction standards, which helped structure data and connect systems across the industry. She added that vendors may be needed to bring payers, providers, and other stakeholders together around shared solutions.

Reasons for Optimism

Klapstein said she remains optimistic because the industry has solved problems that once seemed intractable. Mission-driven professionals continue to enter health care technology, and AI could help gather information and reduce administrative complexity if it is used with appropriate human oversight.

Her central point was that progress depends on understanding both payer and provider incentives and coordinating solutions around them, without losing sight of patients' need for clear cost information.

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