On Episode 116 of Astonishing Healthcare, Lynn Garbee, SVP of Managed Services at Judi Health, joins Justin Venneri in the studio for a lively discussion about the costly battle between payment integrity (PI) and revenue cycle management (RCM) in the U.S. healthcare system. She explains the "claims spin cycle," a pattern of denials and resubmissions that generates an estimated $300–$400 billion in administrative waste annually, and why the denial-driven savings everyone seems to be after aren't really a sustainable strategy.

Lynn also walks through concrete steps that plan sponsors can take right now to be more aware of their plans' expenditures and address waste, including auditing for hidden PI and contingency fees, and managing high-cost claimants in an era of GLP-1s and gene therapies.

Discussion Highlights:

• Healthcare costs are outpacing the entire economy. Spending has climbed from 8% to 18% of GDP over Lynn's career, forcing everyday people to make hard decisions between healthcare, food, and housing - this is the crisis that drives her.
• The PI vs. RCM battle creates a lose-lose cycle for payers and providers.
• PI is necessary - we need to ensure that what is coded is what really happened between a patient and provider - but what began as a way to confirm codes has drifted toward more of a "savings obsession."
• The numbers expose how little the system actually gains - most of the effort just adds administrative cost. Roughly 15% of claims are denied, and about half of those are eventually overturned; on the prior authorization side, ~94% of authorizations get approved, and ~81% of the small share denied are later reversed.
• Contract constraints may be blocking access to more innovative, cost-effective arrangements.

Related Content

• AH113 - From Legacy Mainframe to Judi Cloud™: Modernizing Claims Adjudication, with Andy Kageleiry
• Explaining the Healthcare Claims Adjudication Process for Modern TPAs
• Prior Authorization Guide: Pharmacy, Medical, Dental, and Vision PAs
• Pharmacy Benefits 101: The Importance of the Network

Please visit Judi Health - Insights for more information about this episode and content from the Judi Health team!

In this episode of Astonishing Healthcare, host Justin Venneri sits down with Shane Garoutte, Chief Information Security Officer at Judi Health, for a conversation about cybersecurity and what it takes to protect member data in a landscape where the adversaries don't play by any rules. Shane offers a practical look at why cloud security standards matter so much in healthcare, especially as large-scale breaches continue to affect organizations handling protected health information. He explains why FedRAMP® Ready status is different, how continuous monitoring changes business behavior, and why security must be treated as a company-wide responsibility and "team sport" rather than a narrow compliance exercise.

Shane also offers listeners some timely, actionable cybersecurity tips for remote work and travel, including why multi-factor authentication, physical device awareness, and healthy skepticism around texts and login alerts help reduce risk.

• FedRAMP® Ready status is a differentiated achievement. The real investment is not just technical compliance, but changing day-to-day business behavior through continuous security practices across the entire organization. ‍
• Healthcare security depends on practical habits, not just frameworks – everyone plays a part. Shane shares advice on physical device awareness, multi-factor authentication, passkeys, and healthy skepticism, offering listeners simple steps to reduce risk at work and at home. ‍
• A strong cybersecurity culture is built on trust and teamwork. Security teams should be seen as partners, not punishers; fear can push employees to hide mistakes instead of reporting them early. ‍
• Security maturity is a business differentiator. Shane connects FedRAMP Ready status to Judi Health's cloud-first architecture, scalability, and technology-first approach to benefits administration, showing why employers, plan sponsors, and health plans should care. ‍
• Agentic AI is changing the threat landscape, and fast. The most astonishing story highlights why cybersecurity defenses must be at least as dynamic, adaptive, and creative as AI-powered systems and threat actors move beyond traditional attack patterns.

Related Content & Reference Materials

• Top 10 New Judi® Updates Improving Health Benefits Administration
• AH112 - From Transparent PBM to Unified Health Technology, with AJ Loiacono and Kristin Begley
• What is a Core Administrative Processing System (CAPS) in Healthcare Payer Operations?
• Judi Health Partners with CLEAR as a Preferred Identity Verification Partner to Power Secure, Interoperable Health Benefits Access
• The OpenAI Team's Black Hat Presentation

Please visit Judi Health - Insights for more information about this episode and content from the Judi Health team!

We welcomed Nash Albadarin, PharmD, Associate Director of Clinical Programs at Judi Health™, back to the studio to talk about the evolution of clinical programs and clinical consulting for Episode 114 of Astonishing Healthcare!

What happens when a proactive clinical consulting strategy is employed? What questions should employers ask to evaluate clinical programs? What sorts of results are we seeing with high-touch programs for low-cost alternatives or risk mitigation? Nash discusses his new role at Judi Health and answers these questions, and many more. A pharmacist by training with over 10 years of experience in the PBM industry, Nash describes what a consultative, data-driven approach to clinical programs looks like in practice, and he backs it up with data and real-world examples that show hundreds of thousands of dollars in savings and meaningful reductions in opioid exposure for employers. He also describes a new site-of-care optimization program that's turning heads.

Highlights

• Proactive clinical strategies drive meaningful results and help build trust. For years, PBMs waited for clients to flag a spending problem before responding. Judi Health™ is flipping that model, scrutinizing claims data so the team can bring vetted solutions to the table or contact plan members before red flags appear.
• The results are concrete and substantial. Recent biosimilar conversions drove $130,000 in annualized member savings and $850,000 in annualized plan savings, while Rx Ally cut short-acting opioid day supply by 14.3 days for enrolled members.
• Shifting care from medical to pharmacy - and the site-of-care - yields surprising savings. A newer clinical program, CareShift Health, optimizes site-of-care and shifts select medical drugs to the pharmacy benefit, resulting in a lower net cost.
• Unified data unlocks hidden savings. Medical and pharmacy spend have traditionally lived in separate silos. When you compare them side by side, the excess billing and administration costs tied to provider-administered drugs become clear, and clients are often "blown away" by what they find.

Related Content

• AH043 - Pharmacy Benefits 101: DMP & MTM, Explained, with Nash Albadarin, PharmD
• Health Benefits 101: The Importance of Clinical Programs
• Replay - Improving Metabolic Health in a GLP-1 World
• Poster: The Impact of Text Messaging and Pharmacist Outreach Interventions on Medication Adherence Rates in a Commercial PBM Population
• How PBMs are tackling behavioral health (Managed HC Executive)

For more information about this episode and content from Judi Health, visit www.judi.health/insights.

On this episode of Astonishing Healthcare, Andy Kageleiry (SVP, Enterprise at Judi Health) returns to the studio for a discussion about the state of the technology powering most health plans' and third-party administrators' (TPAs') operations, and how modern enterprise health tech like Judi® eliminates administrative waste, supports flexible plan designs, and unifies medical, pharmacy, vision, and dental claims on one platform. He describes several surprising, common pain points that plan administrators regularly face, including manual claim review, limited data access, an inability to scale or pivot when needed, and point solution fatigue.

Andy also introduces the Judi Cloud™ solution, which lets health plans and TPAs license the Judi platform directly.

• ‍A single claim can be incredibly time-consuming to process, but it doesn't have to be. Eligibility, network status, coverage rules, benefit design, and coordination of benefits all have to resolve correctly in real time. Legacy platforms built on decades-old mainframes can't keep pace, leaving operations teams to close the gap by hand.‍
• Infrastructure point solutions don't fix root cause problems. Every added vendor means another integration, another relationship, and more overhead. That administrative drag contributes to an estimated $1 trillion in annual healthcare waste, slower provider payments, and members who can't reconcile their EOB with their bill.
• ‍A modern, unified CAPS turns the equation around. Judi Cloud lets health plans and TPAs license the Judi platform, enabling them to process medical, pharmacy, vision, and dental claims on one system, cutting manual work, supporting flexible plan designs, and giving clients full, self-serve access to their own data.

Related Content

• Explaining the Healthcare Claims Adjudication Process for Modern TPAs
• Judi Health™ Announces Capital Rx is Now Judi Rx™, Launches Judi Care™ and Judi Cloud™ to Power the Next Era of Health Benefits Administration and Patient Care
• AH111 - Building a Single Source of Truth for Medical and Pharmacy Benefits, with Kevin Sundquist & Liya Lomsadze
• Judi Health Partners with CLEAR as a Preferred Identity Verification Partner to Power Secure, Interoperable Health Benefits Access
• Replay: The Future of Health Benefit Design: How Judi® Powers Seamless Care and Better Outcomes

For more information about this episode, please visit Judi Health Insights.

What does it take to move from fixing one broken corner of healthcare to reimagining the whole thing? On this episode of Astonishing Healthcare, host Justin Venneri sits down with two of his favorite guests together for the first time: Judi Health's CEO, AJ Loiacono, and Chief Commercial Officer, Kristin Begley, PharmD.

The catalyst for this special episode is the company's rebrand, the evolution from Capital Rx, the transparent PBM that built Judi®, into Judi Health, a unified health technology company. AJ and Kristin explain why the "Rx" designation remains a core piece of the company's identity but no longer fully reflects the organization's evolving mission. They also describe the difference between "little T" transparency and the real thing, why incentive alignment matters so much, and what it took to build the first platform to process medical, pharmacy, dental, and vision claims on one system. They also express gratitude to the team and share bold predictions for where health benefits go next.

• The rebrand reflects an expanded mission, not a new one. Capital Rx launched as a transparent PBM, with "Rx" signaling its focus on pharmacy. Over eight years, the company broadened its administrative capabilities, including medical claims processing, and much more - all powered by Judi. Thus, the primary brand: Judi Health, with services harmonized as Judi Rx (pharmacy), Judi Care (medical administration, TPA, navigation), and Judi Cloud (platform licensing for health plans and TPAs).
• There's a real difference between "little T" transparency and true transparency. AJ argues that true transparency means an auditable workflow: full disclosure of all compensation, proof that every customer receives the same pricing and benefit, and no hidden earnings. He calls out the "little H" holding company trick and explains why alignment yields better outcomes for plans and their members.‍
• Nobody had built unified claims processing before. AJ recalls initial skepticism around unified claims. His response: "If Netflix had kept mailing DVDs, we wouldn't be talking about Netflix." To date, no other organization has built a unified claims processing platform. Judi is the exception.
• Unified claims processing will become the standard. Once employers realize they have options, markets shift quickly. AJ, who predicted the rise of transparent PBMs, makes a new call: unified claims will be the industry norm.

Related Content

• Judi Health™ Announces Capital Rx is Now Judi Rx™, Launches Judi Care™ and Judi Cloud™ to Power the Next Era of Health Benefits Administration and Patient Care
• AH100 - The End of the Age of Confusion, It's Time for Acceptance, with AJ Loiacono
• AH067 - Aligned Health Benefits and the Freedom to Unbundle, with Kristin Begley, PharmD
• What is a Core Administrative Processing System (CAPS) in Healthcare Payer Operations?
• AH111 - Building a Single Source of Truth for Medical and Pharmacy Benefits, with Kevin Sundquist & Liya Lomsadze

For more information about this episode, please visit Judi Health Insights.

What actually happens after you hand your insurance card to the front desk at a doctor's office? On the pharmacy side, a claim clears in milliseconds. On the medical side, the same visit can trigger a weeks- or months-long odyssey of coding, clearinghouses, carve-outs, and paper claims before anyone knows what's owed. On this episode of Astonishing Healthcare, host Justin Venneri revisits the "story of a claim," this time following the far more complicated journey of a medical claim.

Joining him are two guests who've been working to improve medical claims processing for years: Kevin Sundquist (VP, Product) and Liya Lomsadze (Senior Director, Product). Together, they trace why medical claims lag, why the system got carved into so many disconnected pieces, and how unifying medical and pharmacy benefits on a single platform - Judi® - changes the experience for plan sponsors, members, and providers.

Highlights

• While pharmacy claims are adjudicated in real time, medical claims often can't even be created on the spot. The clinical record and billing system are frequently separate, and each handoff adds lag and introduces new chances for error – a single mislabeled insurance record can delay a simple lab claim by six months.
• In the medical world, it's common to split a single claim's journey across multiple vendors: in-network pricing to one entity, out-of-network pricing to another, prior authorization to a third, and benefit application to yet another. Plan sponsors, brokers, and consultants need one system and the flexibility to carve out any piece to a preferred partner if they’d like.
• Rigid legacy systems force unnecessary compromises and workarounds. Manual tracking of visits to a chiropractor or physical therapist and hacking deductibles for plan members are all too common.
• Judi’s capabilities are expanding. Payments, care navigation and management, case management, and much more are brought into a more connected experience for members, sponsors, and providers.

Related Content

• AH037 - The Story of a Claim: Redefining the Benefit Experience, with Kevin Sundquist
• Top 10 New Judi® Updates Improving Health Benefits Administration
• AH094 - How Unified Claims Processing Evolved from Pharmacy: Improving Member Care & Operating Efficiency

For more information about this episode and its transcript, please visit Judi Health Insights.

What happens when two consecutive years of double-digit drug spending growth collide with a wave of pricing legislation, executive orders, and policy turbulence? On the latest episode of Astonishing Healthcare, host Justin Venneri welcomes Michael Kleinrock, Director of Research Development at the IQVIA Institute for Human Data Science, back to the show to find out and unpack the findings from IQVIA's 2026 Medicine Use Trends Report.

The headline number is hard to ignore: net drug spending in the U.S. reached $606 billion in 2025, a 10.6% increase year over year, following a 14.4% jump the year before. But the story behind that figure is far more interesting. Michael and Justin dig into what's driving growth (hint: it's not just GLP-1s), why the roughly $670 billion gross-to-net gap matters so much, and why list price still shapes what patients pay even though "nobody pays it." They also explore the uneven reality of the biosimilars market, the trade-offs created by the IRA's Medicare out-of-pocket cap, prescription abandonment, and where spending is headed through 2030.

Please note: IQVIA Institute will be hosting a webinar on July 15th, 2026, featuring a star panel, including past Astonishing Healthcare guest John O'Brien, CEO, National Pharmaceutical Council, Murray Aitken, Executive Director at The IQVIA Institute for Human Data Science, Stacie Dusetzina, Professor, Health Policy & Ingram Professor of Cancer Research, Vanderbilt University Medical Center, and others, to discuss this year's report.

Related Content

• AH071 - A Look at What's Really Driving Drug Spend, and How it Impacts Us, with IQVIA's Michael Kleinrock
• Beyond the Rebate: How Executives Can Better Manage Pharmacy Spend
• AH105 - The Perfect Storm Driving the Future of Drug Pricing, With Josh Golden

For more information about this episode and its transcript, please visit Judi Health Insights.

On episode 109 of Astonishing Healthcare, host Justin Venneri explores pharmacogenomics (PGx) with a trio of experts: Caitlin Munro, PharmD (Clinical Partnerships Lead, Judi Health); Haleh Campbell, PharmD (Clinical Programs Administration Manager, Judi Health); and Houda Hachad, PharmD (Vice President of Clinical Operations, Aranscia). Together, they break down what PGx is, why now is the right moment for broader adoption, and how genetics can shape the way each of us processes and responds to medications.

The conversation moves from the basics to the practical: where the evidence is strongest, which patients stand to benefit most, and what it takes to apply PGx in a way that's clinically responsible and genuinely useful for patients and providers. They also dig into findings from a study the Judi Health team recently presented at the Pharmacy Quality Alliance (PQA) annual meeting and explain why pharmacist support and clinical decision support, not just a lab report, make all the difference.

• PGx adds a piece to the puzzle; it's not a silver bullet. Pharmacogenomics looks at how inherited genetic differences affect the way a person processes or responds to medications. It narrows uncertainty and supports clinical judgment, but it doesn't replace it.
• Several forces are converging to make this the right moment. Testing costs have dropped, evidence-based guidelines from expert consortia are now widely adopted, and hundreds of FDA labels include pharmacogenomic information.
• The strongest use cases involve complexity and risk. Patients on multiple medications, those starting new therapies, and people who've had treatment failures or unexpected side effects often benefit most, especially across common drug classes like antidepressants, cardiovascular medications, and pain therapies.
• Human support drives engagement and trust. Rx Helix data showed that testing adoption was significantly higher among members who received clinician-led, pre-test telephone outreach.
• The future is proactive. With unified claims processing that combines pharmacy and medical data, leaders see a path toward PGx-enabled medication management, identifying patients before therapy begins to optimize treatment earlier in their journey.

Related Content

• Health Benefits 101: The Importance of Clinical Programs
• AH073 - How Low Cost Alternative Programs Can & Should Work, with Jackie Lolos, PharmD, and Haleh Campbell, PharmD
• Replay – The Bridge to Better Healthcare: Uniting Medical and Pharmacy Services on One Platform to Achieve Value-Based Care
• AH060 - A New Approach to Colorectal Cancer (CRC) Screening, with Geneoscopy

For more information about this episode and its transcript, please visit Judi Health Insights.

How can interoperability, policy, and technology come together to solve some of healthcare's most stubborn challenges? On episode 108 of Astonishing Healthcare, host Justin Venneri sits down with Brendan Keeler, Interoperability Practice Lead at HTD Health and author of the popular Health API Guy Substack. Brendan shares his journey from working at Epic Systems to becoming a leading voice in healthcare interoperability, offering insights into the intersection of policy, technology, and workflows.

Together, they explore the current state of interoperability in healthcare, the impact of CMS rulemaking on prior authorizations, and the challenges of modernizing entrenched systems of record. Brendan also highlights the importance of empathy in solving healthcare's complex problems and shares his thoughts on the future of digital identity and patient data access.

• Interoperability is about ubiquity, not just standards. While digital standards like FHIR and NCPDP are important, true interoperability requires widespread adoption across all stakeholders to ensure seamless data exchange.
• CMS rulemaking is driving change in prior authorizations. New regulations aim to digitize and standardize prior authorization processes, reducing manual burdens while potentially increasing overall transaction volumes.
• Modernizing healthcare infrastructure is a monumental challenge. Systems of record like EHRs and claims processing platforms are deeply entrenched, making change costly and complex. Leaders often opt for incremental improvements, such as layering AI on top, rather than full-scale replacements.
• Empathy is key to solving healthcare problems. Bridging the "empathy gap" by making complex issues like benefit design and regulation accessible to non-experts is essential for attracting talent and driving innovation.
• Digital identity is foundational for the future of healthcare. Strong identity verification systems unlock trust and enable secure, seamless data sharing between patients, providers, and payers, paving the way for better outcomes.

Related Content

• How to obtain Rx data and what to do with it
• Replay - Unified Care Navigation: A Critical Component of the Future of Health Benefits Design
• AH064 - Empowering Plan Sponsors: Data Access & Analysis, with Bridget Mulvenna
• Judi Health Policy Update – It’s a Tangled Web of Progress

Disclaimer

This podcast is for informational and entertainment purposes only. The views expressed are those of our guests, do not constitute professional advice, and may not represent Judi Health's/Capital Rx's position on any matters discussed. We make no representations or warranties regarding the accuracy or completeness of the content; information is subject to change and may not be updated.

What makes a healthcare experience feel simple, trustworthy, and effective, even when the work behind it is anything but? On episode 107 of Astonishing Healthcare, host Justin Venneri sits down with Judi Health's Adam Murphy, Senior Director of Design, and Michelle Chambers, Director of UX/UI, to explore how thoughtful UX/UI design can transform healthcare from the inside out.

Adam and Michelle share a practical, behind-the-scenes look at designing for enterprise health tech, where complexity is high, workflows are critical, and poor design can slow decisions, increase errors, and erode trust. They explain why reducing cognitive load matters so much in healthcare, how strong design supports speed and accuracy, and why better user experiences can lead to better outcomes for both operational teams and health plan members.

• In healthcare, design must solve real problems, not just look good, because good UX means smoother workflows and fewer mistakes.
• Human-centered design, driven by genuine user pain points, leads to stronger, more intuitive solutions in health tech.
• Reducing cognitive load is essential, as strong UX/UI in healthcare platforms improves speed, accuracy, and outcomes under pressure.
• Designing with clarity and intention—such as using clear labels and wayfinding—prevents user errors and builds trust and efficiency throughout complex healthcare workflows.

Related Content

• Top 10 New Judi® Updates Improving Health Benefits Administration
• Health Benefits 101: Service Excellence & Scaling an Award-Winning Call Center Model
• AH027 - What is Pharmacy Benefit Management? With Jillian Lonson and Jean Beman, Part 1
• AH058 - Building Judi®, the Healthcare Infrastructure of the Future, with Liya Lomsadze

For more information about this episode, please visit Judi Health - Insights.