Tech-enabled tips for comprehensive FWA prevention Medicaid improper payments have been on the rise in recent years, reaching $37 billion in 2017 up from $29.1 billion in 2015 – a 27% increase over three years. States require Medicaid Managed Care Organizations (MCOs) to take proactive measures that reduce not just fraud, but also waste and abuse. In a recent report, the Government Accountability Office doubled down advising CMS to take additional actions to “improve oversight and help prevent improper payments.” Through the lens of a total payment integrity solution like Pareo™, successful comprehensive FWA management is achievable. Let’s dive in a little deeper and look at the most innovative steps that payers and health plans can take to reduce waste and abuse in 2018. 1. Analyze your post-adjudicated and post-pay claims data. Federally-governed program integrity tactics and guidelines are still forthcoming, says this 2017 report to Congress. But health plans and payers seeking to establish payment integrity in their program can look to this clue, provided by the referenced report, which mentions the Commission looking into “how states validate their encounter data for future rate setting.” This indicates that the Federal government will become increasingly interested in the analytics of claims data, including how financial responsibility was determined (post-adjudicated) and paid for (termed post-pay). It is imperative for health plans and payers including MCOs to leverage data-driven insights in their FWA programs. Pareo, for instance, makes available post-adjudicated and post-pay claims data for analysis and reporting efforts. 2. Intelligent flagging of potential waste and abuse claims. Can your FWA solution flag potentially problematic claims in real-time? Does it autonomously flag potential waste and abuse claims at all, thereby preventing them from escalating into million-dollar mistakes? Pareo offers real-time flagging to assist health plans and payers in identifying and deterring waste and abuse claims. Preventive measures allow a plan to take immediate proactive steps towards successful waste and abuse management, which are a large portion of the improper payment rates reported by CMS (last year, totaling about 10%). Harvard Business Review reported on data from 2012 that found among types of waste for U.S. Healthcare Spending, clinical waste totaled 14% and fraud and abuse 7%. Think about what those percentages translate to in dollars for your organization. Total payment integrity solutions like Pareo are a powerful tool for health plans looking to recoup these costs. 3. Automate auditing workflow. There are several regulatory steps required for claims auditing procedures, an area ripe for automation. Among the most useful provided by total payment integrity solution Pareo are: initiating medical records requests triggers a nurse audit review, medical records details included for nurse audit review process, aggregation of insurance claims data, over-payment tracking, and overlap control. Altogether, this automation adds up to a 5% reduction in administrative costs for Pareo clients. Reducing the administrative costs for a health plan or payer allows for staff to focus on other higher-value tasks that have an impact on the bottom line. Also, a health plan can avoid the negative consequences seen by older payment integrity solutions where a heavy administrative burden results in unnecessary friction in the payer-provider relationship. 4. Generate refund requests and initiate recoupment or recovery services – automatically. In addition to supporting the move away from “pay and chase” activities into more proactive measures, comprehensive technology platforms like Pareo can offer intuitive and automatic recoupment tools for health plans and payers. Among the most powerful is the ability to generate refund letter requests to the provider that include supporting clinical information and to initiate recoupment and recovery services from within the Pareo framework. Streamlining a plan’s recovery efforts is just one of many ways to reduce the work involved in waste and abuse processes. 5. Optimize with predictive analytics and AI capabilities. “It is important to note that while all payments made as a result of fraud are considered ‘improper payments,’ not all improper payments constitute fraud,” writes CMS in an annual report for Congress dated from 2015. In their most recent report, dated November of 2017, CMS states that one of their innovations to prevent FWA is predictive analytics technology (known as the Fraud Prevention System). Health plans looking to minimize improper payments due to fraud, waste and abuse should also use the power of predictive analytics. Pareo is an intuitive platform that offers health plans and payers predictive analytics and AI capabilities designed to prevent FWA claims. In fact, many of the outstanding qualities of Pareo are in line with the proactive measures CMS is taking to prevent improper payments. Claris Health designed Pareo as a total payment integrity platform unlike any other available on the market. By leveraging innovative technologies with a singular, user-friendly interface, our clients have seen dramatic improvements in their FWA programs. Learn more about the ClarisHealth 360-degree solution for total payment integrity, Pareo.
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