Solving the complexity conundrum in healthcare: Candid’s origin story
Healthcare in the U.S. faces a massive and growing problem: administrative costs continue to rise at unsustainable levels–impacting both patients’ access to care and providers’ ability to operate. A significant portion of this issue is tied to revenue cycle management (RCM), a $280 billion industry that consumes over 1% of our nation's GDP on its own. By rebuilding the underlying architecture for RCM to avoid these inefficiencies altogether, Candid Health helps providers automate away tedious tasks so they can focus on care delivery.
The big pain point: unprecedented complexity
Medical billing today is more complicated than ever. Dozens of factors contribute, from regulatory changes to evolving prior authorization requirements, but the biggest challenges include:
- A labyrinth of insurers & rules: There are more than one thousand insurers in the U.S., and while the claim forms are technically standardized, what each payer requires within each field is not. Each insurer has its own idiosyncratic rules—from telemedicine modifiers to medical necessity validation to documentation requirements. The result is a matrix of payer-specific nuance that’s nearly impossible to manage without intelligent automation.
- Value-based care in addition to fee-for-service: VBC models are layered on top of—rather than replacing—fee-for-service. Providers must track multiple performance metrics, calculate shared savings or penalties, and manage alternative payment models. It’s a noble evolution of care, but for billing teams, it adds yet another set of timelines, calculations, and documentation rules.
- Increased patient payment complexity: Financial responsibility has increasingly shifted to patients through high deductible health plans (HDHPs) and other cost sharing mechanisms. This has made collecting patient payments more complex, whether that’s offering payment plans and financing or new approaches altogether like membership models. New transparency regulations like the No Surprises Act are continuously emerging and promise to expand. Without billing software that can handle these evolving requirements, providers end up with a tangle of point solutions to handle them and ultimately with aging Accounts Receivable.
- Direct employer invoicing: More providers are entering direct contracts with employers—especially in specialty care and concierge medicine. These arrangements bypass traditional payers, which might seem simpler, but introduce a new layer of complexity as employers demand significant customization. There’s no standard format for invoicing or adjudication, and some employers use TPAs while others process invoices directly. As a result, billing teams must build bespoke workflows per employer, often outside core systems – increasing the need for agile, interoperable billing infrastructure.
The bottom line is clear: healthcare payments are extraordinarily difficult, leading to massive inefficiencies, bloated billing teams, and a high volume of costly denials and rejections. Legacy systems weren’t built to handle this complexity, and many are failing under the increasing pressure of this changing landscape.
Moving beyond half-measures
Most billing systems in healthcare were built 40 years ago on outdated technology—and they haven’t kept pace with today’s complexity. Key rules are often missing or outdated, so workflows don’t live in systems—they live in people’s heads. Reliance on institutional knowledge makes it hard to scale, train, or maintain consistency. As the complexity multiplied, providers leaned on billers (both onshore and off) to manually fill in the gaps. Over time, this led to an overreliance on workarounds: spreadsheets, increased headcount (both on and offshore), overlapping point solutions, and institutional knowledge. Now, we’re at a breaking point. The system is too complex, too fragile, and too dependent on people just to function. When billing depends on a tenured staff member’s memory, one resignation can cause major disruption.
But for the first time, we have the modern technology to solve the problem at its source—by replacing patchwork fixes with purpose-built infrastructure that scales with the system’s demands.
Solving hard problems at the source
Before founding Candid, we met while working at Palantir, a company built on solving large, intractable data problems, which profoundly shaped our view of the world. We also found inspiration around a few core principles, which are fundamental at Candid:
- Tackle the world’s hardest problems: A core tenet is to tackle monumental challenges others shy away from.
- Bring the best talent together: We are uncompromising on talent, building a team of brilliant minds collaborating on complex issues.
- Solve problems at first principles: Instead of patching over existing problems, the emphasis is on understanding the fundamental nature of the issue and building solutions from the ground up.
As we worked together at Palantir, we recognized the immense opportunity in RCM. We wanted to bring the best aspects of that experience – the problem-solving ethos, the talent, the first principles thinking – but with a singular focus: to do one thing exceptionally well and solve a specific, critical pain point in healthcare.
Candid’s unique & superior approach
Our approach at Candid is fundamentally different because we don’t cut corners. We dive deep to build a platform in partnership with providers, iterating on the solutions with those who live and breathe RCM every day. A few things that speak to the ‘uniquely Candid’ approach include:
- Eliminating manual work (not just making it more efficient): Our core focus is on avoiding the need for costly and time-consuming rework by preventing claims from being denied or rejected in the first place.
- Partnering deeply with our customers: The best products are built by those with a deep understanding of the fundamentals and details, and in RCM the details matter a lot. Our engineering and product teams prefer to work side-by-side with our customers, diving deep to understand their needs and the nuances of their workflows. The result is a solution that truly solves real-world challenges by design.
- Supercharging billing staff: By freeing billers from tedious manual tasks, we allow them to focus on higher-value activities that improve performance – like resolving complicated exceptions, deriving insights from robust RCM reporting, and building custom rules that avoid denials and rejections at the source.
- Constantly raising the bar: We are constantly adapting to the changing environment, shipping new technology that drives exceptional outcomes for our customers by staying ahead of their most critical and challenging problems.
What success looks like
As Candid gets this right, the impact has been profound:
Healthcare organizations using Candid spend significantly less money and time on back-office administrative work that is not core to their mission of patient care. We have enabled a shift from a tedious RCM process to a touchless one.
Key performance indicators reflect this success:
- Net Collection Rate (NCR): >95% average
- First Pass Resolution (FPR) / Touchless Claim Rate: >95% claims require no manual intervention
Beyond financial metrics, our success enables the creation and growth of the next generation of healthcare companies. By providing a robust, efficient, and intelligent infrastructure for RCM, Candid Health removes a significant barrier, allowing innovative healthcare providers to focus on what they do best: delivering exceptional patient care.