Working harder and harder for a 1-2% rate of return on claim spend? It’s time to update your health plan’s payment integrity processes.

Today, health plans and payers are at a crossroads: margins are shrinking, members are savvier, providers are increasingly dissatisfied, data sources are more varied, the talent pool is tightening, and value-based care models are just around the corner. That sinking feeling in your stomach? It’s telling you it’s time for your health plan to conduct a payment integrity audit to determine what areas of your health plan’s cost containment efforts are ripe for innovation.

These are the 6 signs that your health plan is struggling with outdated payment integrity processes:

1. Efforts are Retroactive Instead of Proactive

If your health plan’s payment integrity activities focus on retrospective pay-and-chase rather than proactive (and prudent) steps for prevention, it’s a sign that your PI process is outdated. Payment integrity efforts should a) centralize and b) shift into an overall strategic initiative by health plans rather than being isolated to individual departments.

Transitioning to proactive activities like pre-payment cost reduction greatly minimizes pay-and-chase (retroactive) activities. In 2014, it was noted that the “inflated” costs associated with pay-and-chase were driving industry change. Today, guidelines from CMS and GAO clearly indicate that outsized costs associated with redundant and unnecessary processes (part of what is termed as “waste”) will have no place in the future of healthcare. By re-focusing on prevention, health plans can eliminate waste and streamline costs.

2. Little or No Unified Reporting

You definitely have the data, but do you have the tools to use it? Health plans can improve payment integrity processes by embracing advanced technologies like predictive analytics and artificial intelligence (AI) functions employed by Pareo®. Take a hard look at your reporting functionalities within your healthcare organization:

  • Can you create reports yourself?
  • Can you report on data across all departments?
  • How long does it take to run a report?

Spreadsheets, a once common solution for managing data, cannot keep up with the data demands of our digital age. The process you use to manage payment integrity data should be scalable in order to grow your efforts (and recoveries). Effective reporting relies on advanced technology.

3. Claim Processing Departments Are Competing… With Each Other

If payment integrity activities are taking place across multiple business lines and departments (surveys indicate that as many as 8 departments may be involved in PI at your organization), chances are that competing priorities exist. Siloed and without any clear oversight, objectives from Claims Processing, for example, may interfere or overlap with activities run by the FWA department.

This is a problem that organizations are able to solve with good communication. And for payment integrity to be effective, communication needs to come from a single source of truth. If your current health plan payment integrity efforts don’t provide clear and meaningful communication across multiple departments, it’s time to update your technology solution.

4. Provider (and Member) Friction Continues to Be a Big Problem

Outdated payment integrity processes are likely to cause a high level of provider friction and member dissatisfaction. If these metrics seem high (you’ll know by your provider NPS), consider how upgrading your payment integrity technology can reduce abrasion.

Much of the provider abrasion, which trickles down to health plan members, stems from poor communication (covered in point 3). But there’s more that health plans can do to improve provider relationships, and much of it has to do with having access to better, more accurate data. Additionally, the right health plan technology can complement other payment integrity activities, making a once time-intensive activity like coordination of benefits significantly faster.

5. Administrative and Medical Costs Are Soaring

Seeing an uptick in your administrative and medical costs? You may be able to pinpoint a lack of proper payment integrity processes to rising costs in these areas. Don’t risk the potential impact to your medical loss ratios. Instead, consider how automated technologies (such as claims processing) are saving health plans substantial amounts. CAQH values the benefit of automated claims to be $11 billion.

You probably already know that adding third-party vendors to your health plan operations has the potential to further savings. It used to be that managing multiple business partners and lines of service were a nightmare. Now, the same technology that automates your claims processing and breaks down silos within your organization can help you manage third-party vendors, too.

6. Transparency, You Say?

Health plans may remain “in the dark” because of inefficiencies and operational obstacles inherent in the complex processes attached to the healthcare industry. But that’s all changing as technology seeks to make our industry more efficient. Furthermore, governmental agencies have spoken: Transparency is no longer a polite request. Health plans and payers will need to provide clear, streamlined data in order to remain compliant.

The right approach to a more transparent health organization looks different for every client we speak with. Rest assured that our approach to payment integrity solutions is custom — we make our technology work for you. Deploying a powerful technology like Pareo® will enable your health plan to be agile in today’s (and tomorrow’s) market.

Talk to ClarisHealth about how Pareo® can ensure program integrity at your health plan while improving coordination with providers. 

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