5 Reasons for Health Plans to Choose a Scalable Payment Integrity Technology Platform

Aug 7, 2020

Are you using an assortment of software tools to do work better suited to a platform? You might be missing out. 

When your health plan starts looking to upgrade your payment integrity and fraud management processes with technology, what do you turn to? A tool or a platform? It’s likely not an either/or decision. Situations where only a highly specialized, best-in-breed tool will do the job are myriad. But how can you ensure your organization doesn’t deploy dozens of disconnected tools when a scalable payment integrity platform that drives your health plan’s technology ecosystem is the ultimate goal?

Defining Terms

With technology, you have options when it comes to providing solutions to your challenges. Let’s level set on some definitions of two different approaches to technology solutions.

Tool: a standalone piece of software designed to perform a single specific function or a small set of functions. It is often disconnected from other systems and processes and serves one purpose. Sometimes referred to as an “application” or “product.

Platform: a major piece of software, as an operating system or environment, under which various smaller application programs, processes or technologies can be designed to run. Can be architected as a set of interconnected tools running inside one digital framework and user experience. Typically modular and extensible by design. A platform can be delivered as an integrated solution stack or service.

Both tools and platforms can be extremely useful. But when using them at a complex health plan organization, their limitations and potential become clear. 

Specialized Tools for Specific Needs 

It’s easy to understand the appeal of legacy standalone products, popular apps and best-in-breed tools. Think about the utility of your reliable and familiar claims editor, the specialized nature of a member engagement chatbot, or the competitive advantage provided by a set of algorithms powered by machine learning. And because these tools are often specific to a discrete function of the business, the affected departments often have the autonomy to choose, purchase and implement products on their own. 

Beware complexity

As a result of this low-threshold acquisition process, a mid-size company, on average, uses over 150 software products. And, as this number increases, so does complexity. Not only are there increased security risks and billing owners but also necessary app connections – averaging over 5,000 connections for those 150 pieces of software. Most of these tools lose their usefulness if only one user can access them, or if they’re separated from larger processes and platforms, which necessitate these connections.  

 For example, what good is that member chatbot if it doesn’t seamlessly integrate with the CRM? How efficient is that front-end claims editor if it’s disconnected from auditor prepay and recovery efforts, which are also separate from provider engagement processes? 

 It’s all too easy to find a special tool that solves the problem of the day or translates a manual process into a digital one. But,  understanding that your health plan’s challenges and goals change at an increasingly rapid pace in today’s modern world, it pays to consider flexible technology frameworks that mitigate predictably fragmented processes. 

5 Reasons to Choose a Payment Integrity Platform

With the awareness that stakeholders and processes across the health plan are increasingly interconnected, and that the pace of change is accelerating, adopting technology with flexibility and data visibility in mind is a smart move. For health plans we speak with, that leverage is exactly what the platform approach to technology adoption provides. 

With cost containment efforts driving a significant portion of operational strategy, here are 5 reasons for health plans to choose a payment integrity platform: 


1. Collaboration

As the fulcrum of the healthcare industry, health plan processes involve many stakeholders. Payment integrity efforts alone require third-party services suppliers, audit staff, the SIU and providers all to communicate at various points of the process. The tendency is to seek out collaboration or workflow tools to solve for this need – even though the key information that needs to be communicated exists outside of these tools. 

Fortunately, most platform solutions incorporate communication capabilities in addition to shared access to essential information, which allows multiple audiences to literally be on the same page. In addition, allowing every stakeholder to stay on-platform to perform their tasks creates efficiencies and stronger user habits. 

2. Seamless integration

No matter how comprehensive the functionality native to the technology platform is, outside tools – and even other platforms – will continue to be used throughout the organization. IT teams already have too many tedious integrations to manage: legacy solutions, specialized databases, cloud apps from various software vendors. But platforms turn projects that would usually require dozens of integrations into straightforward one-time connections. 

Integrating accounting platforms, CRMs, service vendor systems, provider systems, claims editors and more with a payment integrity platform provides unique synergies without overtaxing IT. Most are easily accomplished with low-code tools or simple API connections. This integration standard enables real-time data flow (unlike batch FTP) and can help health plans build a technology ecosystem that works toward healthcare data interoperability, which is mandated to be in effect for health plans by January 2021. 


3. Detailed insights and analytics

Because health plans tend to use various disconnected pieces of technology, the associated data tends to stay locked in their respective silos – along with valuable insights the data provides. But gone are the days of matching business goals to queries on last month’s or last quarter’s information. With increasing demands from internal and external forces to tap into the value of enterprise data, health plans are answering the call with the help of integrative platforms. 

Payers can increase their data management and availability capabilities substantially when most of their PI work takes place on-platform. This improvement is especially true with cloud-based platforms. Particularly when coupled with data visualization capabilities, platforms enable a strategic shift in data ownership from a centralized IT function to business groups, giving more users the power to answer any question, with any data, in real time. 


4. Configurability

Health plans tend to have unique processes and needs – even compared to other health plans – that require technology to be flexible to accommodate those differences. For most software tools, that requires custom development, which is either impossible (due to cost) or impractical (due to time). This limitation has led many a health plan down the path of building their own technology solutions with mixed results, which can include the risk of not being able to maintain a self-built tool over time. 

A hallmark of platforms, on the other hand, is configurability, which offers health plans an ideal blend of control and freedom. Solutions like Pareo, for instance, allow health plans to configure fields and workflows and user access to their specific situation, acquire additional functionality as needed, and seamlessly integrate other chosen platforms and tools to their benefit. All without substantially increasing internal IT lift by taking on software development, maintenance and security that splits focus from core operations. 

5. Scalability

The ability to collaborate and communicate with various stakeholders, seamlessly integrate with relevant technologies, derive actionable data insights, and configure your technology ecosystem determines whether your health plan can be flexible and agile. All of these platform benefits add up to a significant competitive advantage for health plans: scalability. 

Platforms support your goals to grow faster and innovate without worrying if your infrastructure and budget can accommodate accelerated plans. So, when you identify opportunities to extend product lines, boost customer service, increase operational efficiency and more that can substantially impact value, you are better poised to act on it.  

Pareo Goes Beyond a Tool 

The most successful technology strategies embrace the rapid pace of change. By taking a collaborative approach that acknowledges the interconnectedness of stakeholders and processes, health plans are much more likely to adopt a technology platform that accommodates varying needs and goals now and into the future. 

Health plans can certainly use Pareo for its discrete functionality – to manage vendors, optimize workflows, conduct data mining and complex clinical audits, engage with providers, coordinate benefits, move more efforts prepay, detect and manage fraud, and use data more strategically. But its potential to transform payment integrity operations comes to fruition when health plans leverage it as an integrative platform.

Pareo works best as the central hub for your health plan, connecting data points across your health information technology ecosystem in a way that allows you to maximize revenues, create efficiencies, achieve interoperability, and effectively manage your cost containment and fraud mitigation goals. 

Now’s the time for total payment integrity

See the ClarisHealth 360-degree solution for total payment integrity in action.

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