AH113 - From Legacy Mainframe to Judi Cloud™: Modernizing Claims Adjudication, with Andy Kageleiry

AH113 - From Legacy Mainframe to Judi Cloud™: Modernizing Claims Adjudication, with Andy Kageleiry

On this episode of Astonishing Healthcare [www.judi.health/podcast], 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. KEY TAKEAWAYS * ‍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 [https://www.judi.health/insights/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 [https://www.judi.health/insights/judi-health-tm-announces-capital-rx-is-now-judi-rx-tm-launches-judi-care-tm-and-judi-cloud-tm-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 [https://www.judi.health/insights/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 [https://www.judi.health/insights/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 [https://www.judi.health/insights/replay-the-future-of-health-benefit-design-how-judi-r-powers-seamless-care-and-better-outcomes] For more information about this episode, please visit Judi Health Insights [judi.health/insights].

AH112 - From Transparent PBM to Unified Health Technology, with AJ Loiacono and Kristin Begley, PharmD

What does it take to move from fixing one broken corner of healthcare to reimagining the whole thing? On this episode of Astonishing Healthcare [https://www.judi.health/podcast], 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. KEY TAKEAWAYS * 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 [https://www.judi.health/insights/judi-health-tm-announces-capital-rx-is-now-judi-rx-tm-launches-judi-care-tm-and-judi-cloud-tm-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 [https://www.judi.health/insights/ah100---the-end-of-the-age-of-confusion-its-time-for-acceptance-with-aj-loiacono] * AH067 - Aligned Health Benefits and the Freedom to Unbundle, with Kristin Begley, PharmD [https://www.judi.health/insights/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? [https://www.judi.health/insights/what-is-a-core-administrative-processing-system] * AH111 - Building a Single Source of Truth for Medical and Pharmacy Benefits, with Kevin Sundquist & Liya Lomsadze [https://www.judi.health/insights/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 [judi.health/insights].

AH111 - Building a Single Source of Truth for Medical and Pharmacy Benefits, with Kevin Sundquist & Liya Lomsadze

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 [www.judi.health/podcast], 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® [https://www.judi.health/enterprise-health-platform] - 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 [https://www.judi.health/insights/ah037---the-story-of-a-claim-redefining-the-benefit-experience-with-kevin-sundquist] * Top 10 New Judi® Updates Improving Health Benefits Administration [https://www.judi.health/insights/top-10-new-judi-r-updates-improving-health-benefits-administration] * AH094 - How Unified Claims Processing Evolved from Pharmacy: Improving Member Care & Operating Efficiency [https://www.judi.health/insights/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 [judi.health/insights].

AH110 - Inside the 2026 U.S. Medicine Use Trends Report with Michael Kleinrock

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 [https://www.linkedin.com/in/michael-kleinrock-9391593/], 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 [https://www.iqvia.com/insights/the-iqvia-institute/reports-and-publications/reports/us-medicine-use-trends-2026]. 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 [https://www.iqvia.com/events/2026/05/us-medicine-use-trends-2026] on July 15th, 2026, featuring a star panel, including past Astonishing Healthcare guest John O'Brien, CEO, National Pharmaceutical Council [https://www.judi.health/insights/ah032---prescription-rebates-agreements-guarantees-and-more-with-npcs-john-obrien-pharmd-mph-and-julie-patterson-pharmd-phd], Murray Aitken [https://www.linkedin.com/in/murray-aitken-iqviainstitute/], 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 [https://www.judi.health/insights/ah071---a-look-at-whats-really-driving-drug-spend-and-how-it-impacts-us-with-iqvias-michael-kleinrock] * Beyond the Rebate: How Executives Can Better Manage Pharmacy Spend [https://www.judi.health/insights/beyond-the-rebate-how-executives-can-better-manage-pharmacy-spend] * AH105 - The Perfect Storm Driving the Future of Drug Pricing, With Josh Golden [https://www.judi.health/insights/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 [judi.health/insights].

AH109 - Unlocking PGx: Evidence, Use Cases, and Implementation

On episode 109 of Astonishing Healthcare [www.judi.health/podcast], host Justin Venneri explores pharmacogenomics (PGx) [https://www.judi.health/insights/pharmacogenomics-pgx-101-what-you-need-to-know-for-rx-programs] with a trio of experts: Caitlin Munro, PharmD [https://www.linkedin.com/in/caitmunro/] (Clinical Partnerships Lead, Judi Health); Haleh Campbell, PharmD [https://www.linkedin.com/in/haleh-campbell/] (Clinical Programs Administration Manager, Judi Health); and Houda Hachad, PharmD [https://www.linkedin.com/in/houda-hachad-9bb29a2/] (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) [https://www.judi.health/insights/what-your-members-dna-could-mean-for-plan-costs] annual meeting and explain why pharmacist support and clinical decision support, not just a lab report, make all the difference. KEY TAKEAWAYS * 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 [https://www.judi.health/insights/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 [https://www.judi.health/insights/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 [https://www.judi.health/insights/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 [https://www.judi.health/insights/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 [judi.health/insights].