The Strategic Approach to Claims Cost Containment

The Strategic Approach to Claims Cost Containment

Competing with other health plan functions for technology priority can lead to missed audit claims cost savings potential. An integrated payment integrity strategy breaks down these internal silos.

With so many moving – and vital – parts within a payer organization, how can we ensure we don’t overlook claims cost containment opportunities? In theory, key departments such as Claim Operations, Provider Audit, SIU and Payment Integrity integrate harmoniously. They have the same goal, after all. Pay claims right the first time. In reality, the division of tasks – and budgets – across multiple payment integrity departments swiftly leads to inefficiency, often in the form of data silos.

These internal silos pose significant challenges to your goals, including accelerating payment integrity results. “Experts believe that healthcare organizations will need to invest in the appropriate tools and infrastructure to effectively manage data,” according to Stanford Medicine’s inaugural Health Trends Report. In an industry that faces ever-changing compliance, regulatory, and technological mandates, warehousing data into inaccessible silos can be crippling.

3 Questions to Diagnose Claims Cost Containment Silos

When considering how to improve returns on claim spend beyond the industry average, health plans often think in terms of their external competitors. Namely, how to access or develop more advanced analytics to root out wasteful spending. Complex concepts offer distinct value, no question. But, if your organization operates with internal technology disparities that perpetuate data silos, meeting increased claims cost savings goals will prove difficult. In fact, this inefficiency and lack of alignment puts 3-7% of paid claims dollars at risk each year.

To root out these fundamental issues that hold you back from real progress on payment integrity, we recommend you ask three questions.

1. Do you have areas of payment integrity responsibility with conflicting goals?

Payment accuracy is multifunctional — from fraud and abuse detection to auditing and quality monitoring. The challenge is that each function’s approach to payment integrity can vary widely. They are incentivized differently. And some areas – data mining and COB, for instance – may even compete against each other.

The success or failure of these programs can impact claims cost savings in different ways. But managing these important functions piecemeal isn’t just inefficient. It’s counterproductive to your potential. The ability to quickly and accurately identify billing errors pre- and post-pay – across all claim types and scenarios – depends on payment integrity working in concert.

An effective payment integrity program should incorporate everything from advanced technology to hands-on clinical, fraud and claims experts. Shared goals allow health plans to make the most of limited resources.

2. Does each function have a separate budget for technology development?

Some organizations centralize every technology purchase under IT’s purview. But budgets are often allocated by functional area. Sometimes those functions responsible for compliance take priority. A health plan simply can’t ignore FWA, COB or policy adherence requirements after all. In other organizations, the departments that best show high returns take precedence.

It makes sense for health plans to focus limited resources on core strengths. But, if you want to progress on payment integrity results, look for areas making do with spreadsheets, outdated databases, shared analytics experts, or a few contingency-based services vendors. These under-resourced functions may struggle with administrative complexity that hampers their expertise.

But with equal access to advanced technology and data insights, they could contribute significant value. Including taking on cost-effective internalization strategies around audits – data mining, DRG review, itemized bill reviews and more.

3. Do you have systems that don’t talk to each other?

With these misaligned functions dedicated to various areas of payment integrity, disconnected technology systems naturally arise. A suboptimal mix of cloud-based, on-premise and manual systems breeds disparity. Inefficiency also plagues these teams in the form of repetitive and redundant tasks.

Without even access to data, each function may create similar analytics for the same KPIs. Some may miss out on opportunities surfaced by real-time data. Those without access to automation and A.I. capabilities will find themselves behind on productivity and advanced skills development.

These disconnects have consequences. In a study of organizations’ IT systems strategies, those who had adopted key technologies and scaled those across functions achieved significant value. Those that didn’t had 15% in foregone annual revenue as of 2018. And the projected gap gets worse. “If they don’t change, they could miss out on as much as 46% of their annual revenue by 2023.”

Resolving Inefficiencies Created by Internal Silos

Once you have identified potential silos in your claims cost containment process, it pays to fix them now rather than later. We know minimizing revenue leakage is imperative – and complex – for our industry. It’s difficult to resolve workflow inefficiencies and ascertain the relative success of our efforts if we cannot bridge the gap between various payment integrity functions.

Every department involved in payment accuracy should have the ability to utilize a stream of aggregated data – data distilled from silos. We have seen health plans structurally integrate these departments to achieve alignment. But even then, technology does a lot of the heavy lifting. A single, integrative platform can resolve these inefficiencies more swiftly while conferring additional advantages.

A single platform approach to payment integrity

Ideally, organizations will navigate to a platform that streamlines both internal and third-party data into a single information portal. Obtaining visibility into overall claims cost containment creates significant advantages for payers. The increased transparency between departments provides strategic insights that allow for:

  • Implementing a more robust payment integrity program
  • Determining what to insource vs. what to outsource
  • Increasing recoveries by at least 5% year-over-year
  • Tracking and accounting for all payment integrity inventory
  • Tracking payment integrity projects from ideation through to project completion
  • Creating little to no provider abrasion
Technology ecosystems as a competitive advantage

The benefits also go beyond the obvious upsides of being able to more confidently manage overpayment prevention and recovery efforts. With good data practices and a technology platform in place, a variety of analytics use cases that drive business value for you and your stakeholders can emerge. It also allows you to deploy advanced, best-in-breed tools like robotic process automation and applications of A.I.

This digital-first approach can cement your competitive advantage. According to McKinsey research, these technology ecosystems often display a “winner-takes-all" dynamic. But this ability to convene a digital health ecosystem isn’t limited to technology giants or national payers.

Pareo Helps Realize ROI on Claims Cost Containment Goals

As an integrated platform for all of your payment integrity efforts, Pareo has a proven track record of helping payers achieve their claims cost avoidance and recovery goals.

Consider how increasing access to technology and data visibility transformed the operations at one of our clients. This Medicaid MCO with 2+ million members wanted to move more claims recovery work internal and use vendors for more strategic opportunities.

They started by implementing Pareo Supplier Optimization to gain insights into vendor performance. They quickly added Pareo Audit and Pareo Clinical to support the build-out of their recoveries unit and internalize key analytics. As a result they:

  • Grew vendor footprint 5x
  • Increased recoveries 2.5x within a single year
  • Grew internal recoveries by 50%

Altogether, their return on investment has exceeded 10x, far surpassing their initial targets. Before Pareo, they lacked an internal payment integrity structure and struggled with under-resourced functions. But they understood their ability to scale was key to achieving a competitive advantage. Pareo met them where they were and enabled them to drive a sophisticated technology ecosystem strategy.

Learn how Pareo can enable strategic moves in cost containment

Pareo Audit is a powerhouse solution for health plans that are looking to launch strategic initiatives around cost containment. Learn more about the benefits that Pareo Audit can bring to your health plan's technology stack by accessing our brochure below.

Using A.I. to Unite Fraud and Payment Integrity

Using A.I. to Unite Fraud and Payment Integrity

Part 1 of our series on how the SIU can use artificial intelligence to overcome common challenges. Bringing together fraud and payment integrity efforts on a single A.I.-powered platform can accelerate health plan savings.

Data and work silos have become a top barrier to health plans’ ability to effectively combat fraud, waste and abuse. Imagine your SIU has been building a case against a suspect provider and requests 50 medical records. At the same time, the provider’s reputation as a bad biller has not gone unnoticed, and another department requests 150 medical records. And just like that, a strong fraud case virtually disappears over a simple communication error. Not to mention the associated provider abrasion. Today, artificial intelligence capabilities have progressed to close these gaps and support data sharing that improves outcomes across cost containment. How could your health plan benefit from using A.I. to align fraud and payment integrity efforts?

Why the SIU and Payment Integrity Should Align

The biggest challenges we hear from SIU leadership ultimately come back to poor communication with payment integrity. Not only the fallout from not knowing about active or previous audits of a suspect provider. But also the need for measuring the team’s efficiency beyond basic metrics of cases opened and dollars saved. These silos can even prevent both the SIU and payment integrity from knowing what information might be available.

You benefit from access to as much intelligence as possible. And this disconnect forces you to work harder instead of smarter. How do these silos emerge, and what could your FWA team do with better access to more timely data on providers?

4 consequences of FWA and payment integrity silos

Limited communication and information sharing between the SIU and overall payment integrity can arise due to several factors. Cultural, political and technology barriers can create the separation. Then, administrative processes emerge in their wake to deepen the divide. As a result of these silos, the entirety of cost containment suffers the consequences:

  1. Potential provider abrasion due to pursuing false positives or duplicated efforts.
  2. Lack of efficiency to get through all leads, cases and audits in an appropriate manner.
  3. Lack of effectiveness in thoroughly managing cases and audits which can lead to missed savings opportunities and undetected fraud, undetected payment policy gaps and even undetected inabilities to follow contract terms both on the provider and the payer side.
  4. Inability to report on SIU progress – and the ROI of the SIU – in a very timely and effective way. This gap also prevents health plans from meeting State and Federal regulatory reporting guidelines, especially for those plans that are Medicare Advantage or Medicaid HMOs.

FWA isn’t necessarily separate from overall payment integrity initiatives – particularly provider audit and data mining. The way each function pursues cost savings may have some similarities and some differences. But ultimately, they have the same goal: paying claims appropriately and efficiently. To eliminate the duplicated effort that can stymie this goal, start by considering what information can and should be shared.

What information should the SIU and payment integrity share?

A.I. – like the fraud and payment integrity efforts it supports – gets its power from varied information that provides additional context for data-driven decision making. If your health plan hasn’t historically shared information across cost containment functions, we recommend you come together on this issue by asking a few questions. Namely, what intelligence does payment integrity currently share with you, and what do you wish they would share? And conversely, what intelligence do you share with them, and what would be beneficial to share?

These questions may seem obvious at first. But particularly when thinking about what isn’t being shared, you may have to probe a little deeper. Consider the information that hasn’t been possible to share as well as anything useful that may have been overlooked in the past. In general, we find that the SIU and payment integrity benefit from shared visibility in five major areas:

  • Provider audits and cases: The SIU can see when an audit is open, and an auditor can be notified when you open a case against a provider.
  • Provider audit history: Utilize past PI audit history for FWA scoring and modeling of AI functions to increase detection capability and accuracy.
  • Medical records: A shared view of medical records cuts down on potential provider abrasion as well as duplicated effort.
  • Provider communications: A shared view of medical records requests and other correspondence and education with providers in question and other case stakeholders. Information may also include interviews (audio or documents) with providers, patients, office staff, etc. related to audits or cases.
  • New schemes or audit types: Two-way sharing of this information provides ideas for each function and allows the SIU to dig deeper into areas of high potential.

If your FWA function has already opened the lines of communication with payment integrity, you are ahead of the game. Even reactive, informal and/or manual processes where you share insights via email or regular meetings, for example, offer value. But to attain a true competitive advantage, you should seek out real-time information exchange that integrates seamlessly into current workflows.

Maximize SIU Effectiveness with A.I.

To enhance the value of the information you exchange with payment integrity, artificial intelligence has developed into a true solution. Highly practical applications of A.I. for health plans already include better detecting complex and previously unknown healthcare fraud schemes. Combining that with intelligence from payment integrity audits and integrating it into the workflow maximizes the effectiveness of both functions.

Alerts and workflow automation

A.I. to unite fraud and payment integrity efforts can look like alerts that notify the SIU of an open audit on a provider, or vice versa. It could also prevent payment integrity from pulling claims for any type of audit on providers with active cases until a determination is reached. This workflow automation allows auditors and the SIU team to be more proactive with their work. It also eliminates duplication of effort, which wastes time and can make a health plan look disorganized.

Role- and user-based security

A.I. and workflow automation can also ensure users have access to information on a need-to-know basis. From limiting who has access to sensitive data like medical records to prioritizing who gets notified of new schemes or audit types. You want to be able to segment this access as much as possible.

Configurable dashboards

What an SIU manager needs to see at any given time will differ from analyst or investigator needs. What medical management or another area of payment integrity needs visibility on also will vary. Being able to define those elements – at the role and user level – and discretely share information allows each expert to have real-time insights pushed to them. No need for ad hoc exchange of already-outdated data. These dashboards also make it easier to track the SIU team’s ROI and efficiency by automating a very manual reporting process.

Pareo A.I. Unites Fraud and Payment Integrity

The value of using A.I. to integrate fraud and payment integrity efforts cannot be overstated. For health plans that use Pareo across all payment integrity functions, a provider’s actual audit history is incorporated into a distinct A.I. model. These results roll up into a provider’s Super ScoreTM so abusive billers don’t get overlooked and inaccurate billers don’t become false positives that waste investigative resources. This model can also provider a “trigger” for the SIU to begin monitoring a highly audited provider.

Moreover, the SIU has full visibility on providers surfaced by Pareo Fraud. You can see all open audits, audit types, amounts, full claim history and the current status – automatically. As an integrated part of the payment integrity technology platform Pareo, it’s a comprehensive, web-based solution for the detection, intake, management, dissemination of information, decisioning, tracking, and reporting on leads and cases that are the result of fraud, waste and abuse.

These benefits just aren’t available with the siloed, legacy FWA tools in use at most health plan organizations. Pareo Fraud can help you quickly convert detection results to leads or cases, communicate relevant information back-and-forth with the audit function, and refer honest billing mistakes for provider education. Advanced integrative technology that provides broader access to real-time data will allow your health plan to modernize the SIU and broader payment integrity efforts alike.


Learn more about the ClarisHealth 360-degree solution for total payment integrity and FWA, Pareo Fraud: Case Management and Detection.

How to Evaluate Payment Integrity Solutions: The Ultimate Guide for Health Plans

How to Evaluate Payment Integrity Solutions: The Ultimate Guide for Health Plans

Payment integrity solutions vendors make many claims. Here are the top 14 areas of evaluation to ensure a perfect fit for your health plan.

Virtually every health plan is looking to address shrinking margins by moving their medical savings from a typical 1-2% today to something above 5% over the next few years. At the same time, the amount of healthcare data is only expanding, making that goal more difficult to address with current solutions. Are you prepared to thrive in this increasingly complex environment? You may find it’s time to evaluate payment integrity vendors and solutions.

Most of the health plans and payers we talk with are in one of two camps: a few self-developed solutions for claims audit and recovery, or scores of piecemeal applications used by the assorted departments dedicated to different areas of cost containment.

No matter your current approach, health plans have an increasing number of advanced technology choices in front of them, all promising “the answer.” New solutions emerge every day to address your interoperability, data and analytics challenges. As your options expand, so do your chances of finding the right fit for your organization – or the wrong one.

What’s at stake? Your rate of recovery.

Choosing the right payment integrity solution for your health plan holds arguably the greatest potential impact on your bottom line. When ClarisHealth conducted a survey examining payment integrity returns on claim spend at the leading national and regional health plans, we discovered a key difference. Those payers who had a scalable technology solution in place more than tripled their rate of recovery. Those that depended on outdated applications that require a great deal of manual intervention just couldn’t compete.

As your health plan looks to evaluate payment integrity solutions emerging on the market, three questions will guide you in your search:

  • What are the most important elements of functionality to consider to address your needs – now and into the future?
  • Is the goal a single, integrative platform to replace manual and piecemeal tools, or an assortment of upgraded solutions?
  • How do the different options – payment integrity platforms, self-developed technology, claims editors, fraud tools, third-party services providers – stack up against each other?

In this guide, we will examine the most important areas of consideration to offer a comprehensive payment integrity checklist for your health plan’s needs.

Functionality is the Top Consideration

When you start to evaluate payment integrity options (and consequently, the tech companies and services providers that develop these solutions), functionality should be the top consideration. Nested under functionality are several areas of evaluation that make up a powerful payment integrity checklist:

1. Supplier Optimization

Services vendors are a big part of most cost containment strategies. So, the ideal payment integrity solution should optimize the value you receive from third-party suppliers. Look for functions like overlap control, contract management and performance reporting all integrated through a single platform. Onboarding a new payment integrity supplier should also be quick and easy. With this functionality in place, you should expect to realize, on average, a 30% increase in supplier efficiency.

2. Audit Workflow and Analytics

If you want to internalize more payment accuracy efforts, you should prioritize functionality that assists in maximizing advanced analytics and hit rates. Look for access to insights needed to create internalization strategies around cost optimization in both pre- and post-pay environments. Because workflows differ greatly between payers, ensure configurability in this area to integrate vendor and internal recovery management efforts. Full visibility on auditor throughput and automation to eliminate routine administrative tasks that bog down valuable staff hours are also key. Altogether, this functionality could boost your internal analyst activity 3x.

3. Clinical Workflow and Analytics

Concerns about increasing provider friction keep health plans from taking full advantage of the skilled clinical coders and nurse auditors on staff. The ability to coordinate seamlessly between vendors and internal resources on provider outreach to prevent overlap, internalize the best analytics from all sources, and fully reconcile each audit removes that limitation. In addition, look for A.I.-powered solutions that unlock unstructured text in the medical record to prioritize claims for review. This advanced functionality could decrease your medical expenditures by 2-4% and reduce the chance of errors.

4. Prepay Workflow and Analytics

With as few as 15 days to make a pay/deny decision on a claim, many health plans choose to “pay and chase.” But with time and quality improvements, health plans can move more audit work prepay. Seamless integrations with data sources, post-pay and service vendors will allow for comprehensive audit management. As will automated workflows and clear visibility into timelines and hit rates. Also look for the ability to extend the most successful post-pay concepts to prepay and take advantage of multiple detection sources. With comprehensive payment integrity technology in place, your health plan can put greater focus on internal prepay avoidance, and a 10% improvement is common.

5. Fraud Detection and Case Management

Relying solely on rules-based detection and fragmented case and allegation management tools that silo data unnecessarily stifle the effectiveness of SIU teams. Consider a comprehensive solution that bridges the audit and investigation divisions of your health plan while maximizing efficiencies with case tracking, investigations, and federal and state reporting. Also look for detection capabilities powered by artificial intelligence to dramatically reduce false positives, focus efforts on most likely leads, and surface novel schemes.

Annual spending on artificial intelligence in healthcare estimated to reach be more than $34 billion in 2025. A recent survey of healthcare organizations found 98% have implemented an A.I. strategy or plan to develop one. And 59% of healthcare leaders expect to achieve a full return on their investment within three years. “Will Artificial Intelligence Finally Make Good on Its Promise to Healthcare?”

6. Reporting and Business Intelligence

Actionable business intelligence allows health plans to drive maximum efficiency and effectiveness. Seek out real-time metrics that can be leveraged for accurate reporting on-demand and configurable role-based dashboards to scale business intelligence solutions system-wide.

7. Provider Engagement

Your payment integrity processes have the potential to damage or improve the payer-provider relationship. Features like electronic overpayment notifications, engagement tools, underpayment management and provider self-reporting can streamline your operations, improve provider relations and reduce costs for both parties.

If this functionality checklist covers more than what your health plan currently needs, that’s exactly the point. You should evaluate payment integrity advanced technology based on its ability to scale. It should grow as you grow. That doesn’t mean you have to take on all areas of functionality at once; a modular approach to implementation brings many benefits to health plans.

Get the Checklist

This evaluation criteria is available as a handy download so you can be confident in your payment integrity solution choice.

Additional Considerations to Evaluate Payment Integrity Solutions

A search for payment integrity technology doesn’t stop at functionality questions, particularly as a health plan evaluates various solutions and/or a more comprehensive platform. The feature set alone will not paint the whole picture. To ensure a technology solution meets your needs today and into the future – and fits within the budget – we recommend you look a little deeper.

After evaluating payment integrity vendors based on functionality, the following areas should also be reviewed:

1. Flexibility

Not all payment integrity solutions offer flexibility, which is why some health plans choose to build their own solution. That path, while offering full customization, also comes with some inherent challenges. Read an analysis on the build vs. buy argument here. Flexible, configurable solutions can mitigate the need for a custom build.

2. Total Cost of Ownership

Factor in maintenance, annual licensing and setup costs. Also consider how much investment and effort it will take to improve the technology and its adoption. Combined with any potential financial improvements, how will ROI be impacted?

3. Integration and Ease of System Implementation

What training and support does the solution provider in question offer? How often do they update their platform, and how well will it integrate with current and future suppliers and providers? Look for integrations that can be 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 scalable technology stack.

Total payment integrity 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. “Why Health Plans Should Choose a Scalable Technology Platform?”

4. User Friendliness

How intuitive is the technology’s user interface and user experience? Evaluate this aspect from the end user perspective as well as managers and decision-makers. Also consider that cloud-based solutions will differ from on-premise in terms of stakeholder engagement, efficiencies and data accessibility. The healthcare industry is increasingly moving all electronic systems to “the cloud” to reduce capital investments in quickly obsolete hardware.

5. Security

Health plans are rightly concerned about data privacy and security. Your technology vendor should have protocols in place to mitigate these concerns. How easy is it to control users’ access and permissions? Look for technologies that allow for controlling access and permissions at object/table-level, at feature-level, and at field-level as well as an audit trail to track changes. Features like single-sign-on, two-factor-authentication, and the ability to insist on password requirements are also ideal.

6. Working with the Technology Vendor

Whether your health plan decides to build its own solution, buy one or subscribe to one, you will be working with this group for years to come. How responsive, reliable and overall customer-oriented are they?

How Does Comprehensive Payment Integrity Stack Up Against Other Solutions?

When we speak with health plans and payers, we find that there’s some confusion surrounding the elements of a robust payment integrity program. Often, they see a claims editor or a FWA tool as a complete payment integrity solution. These tools offer great value but are limited in scope. We regularly uncover gaps and hidden revenue for plans that rely solely on these siloed approaches.

However, a comprehensive payment accuracy platform should seamlessly integrate with these tools to prevent further gaps. Pareo was created to connect external solutions, data streams and third-party services vendors. We recommend you set your benchmark at total payment integrity. But you can use this checklist to evaluate other elements of a payment integrity program.

How to evaluate payment integrity solutions compared to Pareo

Self-developed technology: Self-built payment integrity solutions incur large, ongoing costs for health plans. A self-built solution will require a longer lead time before you can realize ROI. Additional considerations for those considering building an in-house solution are functions that need to be included, expertise, and needed integrations. Pareo can be implemented quickly and offers many immediate benefits to a health plan.

Claims editors: Pareo works in tandem with claims editing solutions by improving their scope and automating much of the workflow.

Fraud tools: FWA solutions, like claims editing solutions, are limited in scope and therefore not comprehensive. They should not be a health plan’s only line of defense in preventing improper payments. If you already use a rules-based tool, you can integrate its data into Pareo.

Third-party services suppliers: A health plan considering third-party vendors doesn’t have to choose between Pareo and their business partners’ solutions. Pareo offers supplier optimization tools that allow for platform integration, improving a payment integrity system’s performance and workflow.



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

Keeping Up with 2021 Healthcare Payer Technology Trends

Keeping Up with 2021 Healthcare Payer Technology Trends

Reviewing the drivers, restraints, challenges and opportunities for healthcare payer technology in 2021.

Those organizations that kept pace with healthcare payer technology trends weathered the uncertainty of this year relatively unscathed. In fact, 2020 made the strongest case yet for health plans succeeding with technology. If your health plan felt less prepared, you may have increased the intensity of your strategic planning efforts to ensure your health plan is on the right track. To that end, let’s explore the industry drivers, restraints, challenges and opportunities impacting these strategies as we look to 2021.

Drivers: Top Motivators for Health Plans in 2021

We can’t reflect on the past year and look forward to 2021 without addressing the novel coronavirus pandemic. It stands to have an outsized impact on the industry for years to come. And even though it didn’t uncover any unknown issues, it accelerated the need for solutions practically overnight.

Because COVID-19 so efficiently highlighted known gaps in the healthcare system – including how far behind many stakeholders are digitally – it is the source of the primary drivers for healthcare payer technology. Health plans must take care of these in the coming year or risk falling even further behind.

Calls for increased transparency

In 2019, we predicted that "health organizations will need to make real upgrades in technology if they haven’t already, or face issues meeting government regulations.” And in 2020, two rules brought this prediction to the forefront.

First, the rules against information blocking were finalized. Though deadlines for compliance have been delayed, the need for healthcare data interoperability has never been greater. This initiative is poised to solve several of the issues worsened by the pandemic, and health plans will continue to push for increased data sharing. Improvements in care quality and decision-making and progress on value-based care programs should result.

The administration also finalized a price transparency rule. It calls for first posting online documents that include prices for healthcare services and medications. A “shoppable” experience for consumers will follow.

The ultimate goal of technology is to break down barriers and allow information to empower a better healthcare system. Health plans have realized advanced technology is only as good as the data that fuels it. With interoperability, data accessibility and transparency as a focus, health plans will naturally evolve to start questioning any process within their organization that inhibits information sharing.

“Health plans that are able to adapt to these changing trends are far better positioned for long-term success.” FierceHealthcare

Work-from-anywhere environment

Improving data accessibility extends to internal operations at payers as well. The modern work-from-anywhere environment has arrived. The technology that supports it must follow. Health plans have adapted to the “do more with less” credo that pervades most industries, but manual and labor-intensive processes only contribute to the administrative burden.

By adopting integrative technology platforms, health plans can eliminate data silos and improve collaboration and oversight. As payers start to experience the big picture benefits of advanced technology, health plans will be able to work towards becoming more proactive and less reactive.

Changes in membership mix

Health plans have started to experience shifts in their lines of business. This year has brought an influx of members into Medicare Advantage, Medicaid and ACA plans. While severe impacts to employer-sponsored plans have not yet materialized, how consumers think about healthcare coverage has changed for good.

Members are tasked with owning their own healthcare experience and expect the relationship with their health payer to be frictionless and intuitive. Not meeting consumer demand will open payers up to disruption. But if health plans make technology decisions with their eye firmly on the member, they will also find numerous opportunities to improve program integrity efforts.

Changing competitive landscape

Increasing consolidation among health systems and payers is also motivating health plans to innovate. They understand that relying on legacy technology and paper-intensive processes minimizes the ability to scale. Health plans are taking steps now to upgrade their position.

And not a moment too soon. The long-predicted disruption to healthcare has arrived as top retailers have made bigger inroads in the industry. In an increasingly consumer-driven environment, demonstrating value to members and employers is key. Payers with a tech-first mindset – and the ecosystem to match – will have the strategic advantage in these situations.

At the same time, health plans will see more technology vendors looking to leverage experience with other industries into similar successes in the healthcare sector. Technology can help rapidly improve ROI on the claims recovery process. But health plans will need to shrewdly evaluate these solutions to ensure a good fit.

Restraints: Navigating the Roadblocks Health Plans Face

Health plans have long known the advantages of advanced healthcare payer technology. But the usual suspects continue to block progress. Slim margins, data security concerns and shortages in skilled workers could prevent health plans from making headway on their goals this year.

Uncertain medical loss ratios

The uncertainty around how the ongoing pandemic will affect medical loss ratios has some health plans putting strategic technology investments on hold. Profits at most insurers have risen this year, but many industry leaders predict a forthcoming correction. Combined with the historic struggles to efficiently and effectively transition to digital processes, taking on new technology projects may feel too risky in the short-term.

Health plans can overcome this perceived risk by seeking out solutions that surface quick wins and set them up for long-term advantages. Look for speed to value. Enterprise healthcare payer technology that is easy to implement, builds empathy with stakeholders, improves efficiency and reduces team frustration will pay dividends.

Concerns about data security

Dealing with large amounts of patient data makes health plans a prime target for security breaches. And the entire industry trying to quickly integrate numerous data sources has the potential to create vulnerabilities in the system. But health plans moving too slowly with technology adoption can lead to irreparable harm as well.

Current manual approaches to PHI – locally stored data, paper faxes, etc. – are even more vulnerable than secure digital processes. Modern technology, on the other hand, can grant you more control. It allows you to be more granular with granting access to PHI, for one. It also creates a digital log of access. For even greater peace of mind, seek out HIPAA-compliant technology vendors that pursue HITRUST CSF and SOC 2 certifications.

Unexpected costs of outsourcing

The data sharing and transparency regulations and other technology initiatives have payers concerned about how they will pay for and staff these projects. Additionally, health plans will have to overcome learning curves, fear of change and other internal challenges as they select solutions and look for increased returns. The vast majority – 79% – will look to outside vendors to cover these gaps.

Predictable costs will make these burdens easier to bear. Off-the-shelf solutions that are easily configurable will prove more cost-effective than custom-built technology. And a strategic combination of insourcing and outsourcing activity based on health plan core competencies will also optimize spend. A partner and technology that allows you the flexibility to decide – service by service – whether to outsource or insource based on your cost-benefit analysis will better poise your health plan to scale effectively.

Challenges: Factors for 2021

Internal restraints aren’t the only barrier to success with healthcare payer technology. Let’s look at the broader industry factors that could challenge health plans in 2021.

Provider financial instability

So far, providers have borne the brunt of the pandemic financially, and their survival is at risk. Healthcare payer technology strategies will need to support this valuable group. Without a broad network of providers, health plans will find it difficult to advance on engaging members and lowering healthcare costs. Health plans that use technology to focus on this relationship can overcome this challenge. Consider solutions that ease providers’ claims payment administrative burden and support real-time communication.

Slow adoption of value-based care

Value-based care continues its slow adoption among providers. Those participating in alternative payment models performed better than their fee-for-service counterparts in 2020. They also are more likely to pursue population health improvements that stand to keep their patients healthier during the pandemic. But other providers may hesitate to take on more risk.

Health plans can support providers in this transition with healthcare payer technology that overcomes trust and abrasion issues. Increase data transparency so both sides of the relationship are working from the same playbook. Come to agreement on interpretations of value and quality. And measure everything: clinical quality, consumer experience, return on investment, and more. Then share those data insights and work together on continuous improvements and innovations.

Considerations for selection to participate in CMS’ largest bet on value-based care to date “will include an entity's risk-sharing experience, IT infrastructure, compliance and beneficiary engagement.” Healthcare Dive

Uncertain political landscape

A new administration will be in place this coming year, including new leaders at government healthcare agencies. Stabilizing the coronavirus response will likely be the focus of any short-term action, which most healthcare stakeholders should welcome. Whether or not additional burdensome regulations or market changes will be introduced is currently unknown. Agile, tech-forward health plans will be positioned to succeed no matter what happens on this front.

Opportunities: Chances to Excel with Healthcare Payer Technology

While challenges abound in an uncertain healthcare environment, so does opportunity. Changing member behavior and technology advancements may both offer health plans the chance to succeed with their digital transformation goals.

Members open to engagement

One unexpected benefit of this year is how it has opened up avenues for member engagement. People want to hear more from those responsible for their care. They have embraced home health. And they have welcomed technology into their healthcare unlike ever before.

Payers have caught on to the fact that providing improved member services is a differentiator in a consumer-driven market. By offering convenience and addressing social determinants of health, plans can offer broader benefits with perceived higher values while lowering costs. CMS has made it easier for health plans to offer supplemental benefits, another incentive for offering them. With health plans expanding coverage in this area, digital health adoption will continue to grow.

"Leveraging the power of your lifestyle and combining it with research and technology will enable people to take full control in their health journey. With the cost of healthcare rising, providing tools to prevent or reverse diseases that could be costly for patients and the system is a win-win.” Health plan Chief Innovation Officer

Advancements in technology

Technology advancements continue, as API standards are enacted and artificial intelligence capabilities improve. Plans can leverage the mountains of data they collect through improved data analytics technology, reducing time to reports and empowering real-time decision making. And these updates come just in time. Expansion of digital healthcare may prompt more incidents of improper payments and bad actors. But A.I. has also pushed forward opportunities to proactively combat fraud, waste and abuse. By going deeper and wider into the data to push likely leads to you, new schemes won’t pass you by. This improved technology can better integrate the SIU with overall payment integrity as well.

Through secure integrations, data sharing could be a hurdle that health plans finally surpass. Cognitive collaboration capabilities will emerge for health plans if they utilize the right technology solutions. Empowering users to break down barriers within their organization will drive efficiencies and improve the care continuum.

Partner to Make 2021 the Best Year Yet

Health plans can stay ahead of the curve by making strategic investments in change, particularly surrounding transparency. Integrative technology and shifts in program integrity approaches will allow payers to continue to gain ground and focus on proactive efforts, particularly when it comes to claims recovery and payment integrity.

Extending your competitive advantage transcends trends. Fortunately, a comprehensive technology platform like Pareo allows health plans to scale and improve processes, harness the power of A.I., increase medical savings, and accelerate ROI. Talk to ClarisHealth about how Pareo can keep you a step ahead of healthcare payer technology trends – no matter what the future brings.


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

Will Artificial Intelligence Finally Make Good on its Promise to Healthcare?

Will Artificial Intelligence Finally Make Good on its Promise to Healthcare?

Artificial Intelligence is making the leap from much-hyped “trend” for healthcare technology to more widespread adoption. Here’s what A.I. is — and isn’t — and how health plans are proving its value.

Artificial Intelligence for healthcare has come a long way since 2017 when IBM Watson Health, the A.I. supercomputer fell short of its high expectations. A.I. is a powerful force in advanced healthcare technology and is poised to disrupt the industry. And, due to several converging factors in 2020, adoption accelerated. Let’s explore what A.I. is — and isn’t — and why it’s here to stay despite current limitations. But first, a few definitions.

Defining Artificial Intelligence

While varied stakeholders have found value in applications of artificial intelligence for healthcare, confusion remains about what it is and isn’t. When the industry uses buzzwords like “A.I.” and “machine-learning” to describe product functionality, know these words are easily misunderstood and thus, often used incorrectly. Let’s level-set with some working definitions of terms you might encounter when evaluating advanced healthcare technology.

Artificial Intelligence: Intelligence applied to a system with the goal of mirroring human logic and decision-making. A.I. is utilized for the purpose of successful knowledge acquisition and application, which it prioritizes over accuracy. A.I. simulates intelligence (the application of knowledge). It includes many subcategories and is often separated into three types: narrow, general and super.

Narrow Artificial Intelligence: Created specifically for a single task or to solve a single problem. Almost all applications of A.I. In use today are of this type.

General Artificial Intelligence: A type of broad and adaptable A.I. that can think and function just like humans. Not generally available today, though advancements in neural networks may offer a path to this reality.

Super Artificial Intelligence: A theoretical type of A.I. that is imagined to exceed human cognition significantly. It should emerge from the exponential growth of A.I. algorithms self-learning. Does not currently exist.

Machine Learning: An application of A.I. that allows a system to learn on its own. ML learns from data, and it aims to increase accuracy (success is a lesser concern). ML simulates knowledge. Source Includes both supervised and unsupervised methods.

Supervised Models: Algorithms designed to learn by example, based on labeled datasets that provide an answer key that the algorithm can use to evaluate its accuracy on training data. The term “supervised” learning originates from the idea that training this type of algorithm is like having a teacher supervise the whole process. When training a supervised learning algorithm, the training data will consist of inputs paired with the correct outputs.

Unsupervised Models: Machine learning technique that finds and analyzes hidden patterns in “raw” or unlabeled data. By ignoring labels altogether, a model using unsupervised learning can infer subtle, complex relationships between unsorted data that semi-supervised learning (where some data is labeled as a reference) would miss. And do so without the time and costs needed for supervised learning (where all data is labeled).

Data Analytics: Process of examining data sets in order to draw conclusions about the information they contain, increasingly with the aid of specialized systems and software. Data analytics technologies and techniques are widely used in commercial industries to enable organizations to make more informed business decisions and by scientists and researchers to verify or disprove scientific models, theories and hypotheses.

Predictive Analytics: Historical data that has been collected is utilized to try and predict behavior/outcomes (often called Data Science). To analyze data, it is routed into a report, at which point humans or artificial intelligence apply multiple factors to make predictions about expected outcomes. Though based on decades-old technology, “predictive analytics” often implies that a machine has performed the analysis and offered a prediction (rather than a human).

Neural networks: Seeks to simulate human brain processing, which is facilitated by networks of neurons. At its simplest, a neural network processes information in three layers: 1. Input layer where data enters the system, 2. Hidden layer where data is processed, and 3. Output layer where the system decides what to do with the information.

Deep learning: Allows for increasing numbers of layers through which data passes, where each layer of nodes trains on a distinct set of features based on the previous layer’s output. The further you advance through the layers, the more complex the features your nodes can recognize, because they aggregate and recombine features from the previous layer.

Overcoming Concerns About Artificial Intelligence for Healthcare

Though experts have long predicted that artificial intelligence for healthcare would take hold, adoption has progressed slowly. And no wonder. The industry has been historically hesitant in its pursuit of advanced healthcare technology. And for clinical care applications, particularly, providers express discomfort with “black box” A.I.

Forbes points out, “As humans, we must be able to fully understand how decisions are being made so that we can trust the decisions of AI systems. The lack of explainability and trust hampers our ability to fully trust AI systems.”

In addition to explainability issues, lack of broad access to healthcare data stymies effectiveness of A.I. Data silos and patient data privacy concerns both limit access that could push the technology forward. But federated learning could help overcome this barrier. It’s a privacy-focused approach to machine learning that allows companies to collaboratively form more representative data sets without sharing raw data. Once-generic models get smarter over time through decentralized data and decentralized compute power.

This approach could also help overcome another perennial concern about A.I.: model bias. A.I. systems learn to make decisions based on training data, which can include biased human decisions and amplify historical or social inequities. It’s a complex problem with life-and-death consequences in using A.I. for healthcare. But leveraging larger, more varied data sets, increasing transparency of processes, improving awareness of potential bias in A.I. outputs, and continuing to augment machine decisions with human expertise will mitigate this issue.

2020 Makes the Case for A.I. in Healthcare

Early adopters in the healthcare payer sector understand the benefits and risks associated with A.I. all too well, and skepticism of vendor claims of A.I. is high (and rightly so). However, the value of artificial intelligence in healthcare increased significantly in 2020 due to two primary drivers.

First, A.I. compute has been doubling every three and a half months making applications faster and cheaper. In just a year and a half, large image classification systems are training much faster, from three hours down to 88 seconds. Progress on natural language processing (NLP) classification tasks is also “remarkably rapid.”

Second, the novel coronavirus pandemic accentuated the foundational weaknesses in the healthcare system. All at once, various stakeholders around the industry sought A.I. applications to address the resulting challenges. They also found value in collaborating to achieve the data access, sharing and quality needed to power these tools. Solutions for drug discovery and disease prediction emerged at a record pace. And the data and research breakthroughs promise to continue to push the industry forward.

Applying A.I. to Advanced Healthcare Technology

A.I. is expected to permeate every facet of the industry healthcare, with annual spending on artificial intelligence in healthcare estimated to reach be more than $34 billion in 2025, up from $2.1 billion in 2018. A recent survey of healthcare organizations found 98% have implemented an A.I. strategy or plan to develop one.

The current applications of AI in healthcare are narrow and highly functional. But as adoption accelerates, it generates momentum which perpetuates the benefits of A.I. In fact, 59% of healthcare leaders expect to achieve a full return on their investment within three years.

Some current applications of A.I. for health plans include:

  • Detecting and preventing fraud, waste and abuse
  • Value-based care initiatives
  • Claims management
  • Supporting coordination of benefits
  • Surfacing business intelligence insights
  • Increasing effectiveness of clinical audits
  • Member outreach and engagement
  • Automating administrative processes
  • Predicting healthcare needs

“With AI, the more quickly organizations in early or middle stages of AI deployment move forward, the sooner they will overcome uncertainty and unlock the rewards of this powerful business tool.”

So far, no single A.I. vendor has emerged as the leader in the industry. In the coming year, healthcare payers will continue to see technology disruptors enter the market. For many plans, a selection of effectively managed vendors will be the most effective strategy to drive ROI. Though health payers will have to be careful of hype, particularly from tech vendors of artificial intelligence solutions for healthcare who lack industry experience. What works for one sector — say, finance — does not easily translate into healthcare, which is often more complex, more heavily regulated, and more data sensitive.

How Your Health Plan Can Find Value in A.I.

You might think that being a fax/email/spreadsheet organization means your health plan is woefully out of date, but you might not be as behind as you fear. Even as the early adopter stage of A.I. comes to an end, it still confers a competitive advantage for those health plans that can scale its use. But now is the time to move. Envision the role A.I. will play in your organization in the years to come and develop a strategy roadmap to invest in and leverage A.I. assets.

It pays to keep in mind that, while A.I. can offer much needed technology advantages to health plans, it can’t solve all payment integrity challenges on its own. Ensure your health plan has the best chance to realize these benefits now and into the future. You can and should deeply question your technology vendor and demand specifics around their solution’s A.I. capabilities.

Health payers will need to see all the moving parts of their tech ecosystem, including real-time metrics on advanced healthcare technology performance, in order to prove its value even if A.I. capabilities are touted. Increasing visibility across disparate departments, deriving insights from siloed data, realizing cost savings, and augmenting human expertise and productivity are exactly the type of improvements that show A.I. at its best.

Pareo – Powered by A.I.

At this stage, A.I.- powered solutions may be more commonplace than you realize, but the true value offered by artificial intelligence for healthcare varies from vendors to vendor. The most powerful way to harness A.I. capabilities is when they are applied as part of a broader solution, an advantage provided by an integrative platform like Pareo®.

Pareo® offers multiple applications for of A.I. as part of a broader “one-source” system insight platform for health plans and payers. Deep learning powers the fraud, waste and abuse detection and prevention solution that integrates seamlessly with overall payment integrity. With its multi-dimensional view of data, it offers distinct advantages over rules-based tools.

Pareo also leverages artificial intelligence to increase auditor efficiency and effectiveness with clinical audits. It integrates OCR technology to make unstructured data searchable, filterable and sortable. Then, NLP and machine learning applications of A.I. help auditors prioritize cases for review and automatically tag relevant documentation. The solution also generates confidence scores for denials so cost containment leaders can better trust results.

A.I. is a crucial technology for your health plans to adopt or expand upon throughout your organization. Set yourself up for success and start using artificial intelligence now to address the challenges in healthcare brought on by increasingly complex data.



Learn more about the ClarisHealth 360-degree solution for total payment integrity and FWA, Pareo Fraud: Case Management and Detection.

Evaluate Payer-Provider Portals on These 4 Features

Evaluate Payer-Provider Portals on These 4 Features

Go beyond the basics with a payer-provider portal that drives engagement and decreases costs.

How would you characterize the health of your relationships with network providers? If yours is like many health plans, those relationships could always improve. And providers agree, with a relatively high number of them reporting low levels of trust in public and private payers. Without collaboration, the shift to value-based care and the coronavirus crisis could push these strained partnerships beyond their limit. But payer-provider portals may provide an answer to this dilemma. Increasingly, health plans are using them to come together on claims payments and other communication needs.

How to Choose a Payer-Provider Portal

When providers rank top payer performers, they reveal a link between efficiency and trust. Those health plans that simplify claims processing, offer transparency in their transactions and are quick to reimburse will win these relationships. With these goals in mind, we identified 4 features your payer-provider portal must have to drive engagement and increase revenue.

1. Overpayments and underpayments

Both health plans and providers want a clean claims process that reduces the administrative burden and speeds reimbursement. The current process at most payer organizations relies too heavily on paper-based, manual activities that lack context and create abrasion. Portals provide the opportunity for two-way, real-time secure communication that eliminates the need for fax and mail.

At the most basic level, your portal should support both health plan auditors communicating on overpayments and providers reporting underpayments. Providers need to quickly see the status of all claims, including visibility on medical records requests and details on denials and appeals – down to the line level. Form letters don’t include this context, requiring follow-up phone calls that add even more inefficiency to the process. But combined with alerting for claims that need input, the payer-provider portal workflow accelerates audit resolution.

2. Credit balance, recovery posting and reconciliation

A recent survey confirms providers find revenue cycle management most in need of innovation and disruption. But they also said lack of alignment between healthcare stakeholders – including payers – could stifle progress on this front. Payer-provider portals hold the potential to ensure clean accounting systems for both sides of the equation.

For providers, an at-a-glance view on their total claims with you, broken down by those pending, accepted, denied and in review is essential. They also find value in the ability to identify and resolve credit balance issues. As providers accept denials, this should automatically initiate recoupment and recovery on the payer's side to ensure full overpayment tracking and reconciliation with no gaps. This seamless process should extend to unsolicited refunds as well.

With all of these activities connected, payer auditors get a view on the net recoveries and claim spend in real-time. Full analytics on the effectiveness of these activities – reports, dashboards and a payment forecast – increase this value.

3. Seamless integrations

Providers – like many in healthcare – operate with arguably too many siloed tools. They may already use multiple portals to work with various payers. Many health plan auditors work in a similar environment. Jumping in and out of several disconnected systems wastes time and leads to mistakes. But payer-provider portals that minimize additional burden on this front benefit both sides of this relationship.

For providers, the ability to connect the portal with their EHR allows for increased efficiency on medical records requests. They can see helpful information from both sources at their fingertips and quickly access exactly what they need for each task for faster, more reliable processes. For auditors, keeping the portal on-platform with their current auditing workflow minimizes repetitive tasks and speeds turnaround times. This integrated framework is especially useful for the accelerated timelines of prepay audits

4. All-in-one information access

Think of all the different ways you communicate with providers and deliver information. And yet, over 30% of providers report not communicating with payers at all. No wonder providers and payers both feel these relationships lack alignment. With information constantly changing, the payer-provider portal holds potential to act as a single source of truth.

Use the portal to distribute always-up-to-date provider manuals, procedures, correspondence, newsletters, how-to guides, and other provider education and communications. In return, providers don’t have to manually complete forms and figure out how to submit them or worry that out-of-date information will prevent timely claims payment. With dashboard notifications that promote self-service, providers and health plans can stay on the same page.

Pareo Payer-Provider Portal Increases Engagement and Revenue

The relationship between health plans and providers requires more collaboration than ever. As our industry shifts toward transparency, you need a technology platform that supports that goal.

A payer-provider portal like Pareo Provider can help you demonstrate value on the fundamental communication needs of claims payment accuracy. Reduce the administrative burden. Make it easier to respond to medical records requests. Provide context on claims overpayment submissions and respond quickly to underpayments. Increase efficiencies for health plan auditors and revenue cycle managers alike. This foundation of trust paves the way to coming together on initiatives of greater strategic significance like value-based care.


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