Tracking the Information Blocking Rule: It’s nearly final, but is the healthcare industry ready?

Tracking the Information Blocking Rule: It’s nearly final, but is the healthcare industry ready?

Despite public concern, the final rule is moving forward. Meanwhile, a recent survey says only 18% of healthcare execs understand the seismic implications.

Both the Information Blocking Rule and the Interoperability Rule (collectively referred to as the Proposed Rules) have been pushed to the final phase: a review by the OMB. This advancement of rules aimed to ease data sharing underscores HHS’s interest in improving interoperability without further delay, especially when it comes to the Information Blocking Rule. ONC’s proposed rule has undergone significant criticism by key industry players, but rather than being reviewed and revised, the rule was moved forward to the final stages. 

A recent survey by Deloitte indicates that a significant portion (43%) of health plans are well-prepared to meet or even exceed the parameters set forth in the final rule, according to the CTOs and CIOs surveyed. Healthcare executives in a separate survey, however, tell a different story: Only 18% of those surveyed in this study say they understand the implications of the Proposed Rules. Most (65%) report only being vaguely familiar with the set of data sharing rules. This is a problem because the Proposed Rules are sure to have seismic implications on the industry. 

As the rules move to their final phase, we will evaluate the concerns raised by the public comment period and the continued efforts of large healthcare stakeholders for clarification on the proposed Information Blocking Rule. We will also look at the logistics of implementing these rules, asking how our industry may – or may not be – well-prepared to tackle interoperability once and for all. 

ONC’s Information Blocking Rule Raises “Significant” Concerns

Let’s start with what we can all agree on: the goal of seamless data sharing is a noble one. Nearly all stakeholders understand that patients need better access to their data. In this increasingly digital age, rules must evolve accordingly to further define a patient’s right to access their medical data. But for some major healthcare industry experts and organizations, the progression of the Proposed Rules to final review is where the rubber meets the road. In particular, many feel ONC’s nearly final Information Blocking Rule doesn’t do enough to define important data sharing elements (specifically, electronic health records lack a standard definition). 

In addition, strong concerns have been raised surrounding data privacy over open API connections. Patient medical data is incredibly valuable, say experts, and many agree that patients should have the ability to control when and where their data is used. Experts worry that if patient data is commodified (for example, by third parties), it could result in unintended consequences for the patient. To these experts, a lack of insight into when and where patient data may be used (and who controls those rights) is a major oversight of the Proposed Final Rules. Read more about how API connections improve data sharing here.

“AMA is calling for controls to be instituted that establish transparency as to how health information is being used, who is using it, and how to prevent the profiteering of patients’ data.”

(source)
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What's on the table: Two Rules, Same Goals

Both ONC and CMS issued proposed rules that aim to tackle the complex problem of data sharing. Though used interchangeably and collectively at times, these are two separate rules. Here’s a look at each one.

Proposed Information Blocking Rule

  • Released by: ONC in February 2019
  • Status: Under OMB Review. Anticipated final release this year.
  • Has been criticized for being overly broad and administratively complex

Proposed Interoperability Rule

  • Released by: CMS in February 2019
  • Status: Under OMB Review as a “long-term action item” scheduled to be finalized no later than March 2022

These rules are collectively termed “the Proposed Rules” and were issued by offices under HHS as part of a broader goal to improve patient access to health data

The proposed implementation times – some as soon as January 1, 2020 – have also been called out by critics. Rapid adoption is a risk, particularly when awareness and understanding of the rules is relatively low. Groups have called on ONC and CMS to delay implementation and stagger rule deadlines. If this does not occur, the Proposed Rules as currently written will result in overlapping deadlines, which “creates layers of complex requirements for both providers and vendors,” says Mari Svaickis, Vice President of Federal Affairs for the College of Healthcare Information Management Executives (CHIME).  Additionally, the Information Blocking Rule will require EHR and health IT vendors to overhaul products, creating a “substantial industry shift,” according to Svaickis. It is unclear whether or not OMB will address implementation times in their final review. 

The Health IT Advisory Committee (HITAC) has called on ONC to address specific concerns surrounding the proposed Information Blocking Rule. HITAC, a product of the 21st Century Cures Act, regularly recommends policies to ONC. In addition to data privacy and implementation concerns, the group made other recommendations to ONC in order to ease the burden of the proposed Information Blocking Rule on providers and vendors. Their recommendations are threefold:

  1. Create a new version of the health IT certification (versus updating the 2015 certification)
  2. Better define some of the terms of the rule itself
  3. Ease the penalty for stakeholders found to be in violation of the rule, currently written as $1 million per instance of information blocking

Supporters Say Benefits Outweigh Risk

The goal of providing patients greater access to data aligns perfectly with some organizations, particularly those who feel health plans are able to shoulder the interoperability burden. Health plans have made progress towards addressing interoperability already, with increasing focus on API integration (only 3% of health plans surveyed don’t use API). 

AMGA President and CEO Jerry Penso, M.D. wrote, “Access to claims data from all payers has been a longstanding priority for AMGA and its members. CMS’ latest initiatives support AMGA’s work by allowing providers to access Medicare claims data. If successful, CMS’ initiatives should inspire commercial insurers to follow suit in data sharing, a crucial step in delivering the most effective care for patients and improving health outcomes.” Though he was specifically referring to another data-sharing initiative, CMS’ “Data at the Point of Care (DPC)” pilot, the implication is that AMGA supports all of CMS’ interoperability rules. 

Where to from here?

The concerns are on the table, and the rules appear to be moving forward anyway. Detractors are likely still on guard from the rollout of previous rules, namely what was previously called “Meaningful Use” of electronic health records, which fell short of delivering on its promises. Just over 40% of health plans say they are already addressing interoperability as positioned in the Proposed Rules. But that still leaves 60% of health plans in limbo. 

ClarisHealth has been tracking the Proposed Rules closely over the course of this year. For more on the topic, please see the following articles:

As a provider of comprehensive technology, ClarisHealth is well-versed in supporting strategic interoperability initiatives at health plans of all sizes. We work with vendors, providers and health plans to make total interoperability possible by utilizing our technology solution, Pareo. Health plans aren’t meant to work in silos. Find a partner that can help. Reach out to ClarisHealth today to begin a conversation about how best to prepare your plan and its vendors for adhering to the proposed rules.

Talk to ClarisHealth about how Pareo® comprehensive payment integrity technology is helping health plans deliver on their most advanced digital strategies.

No, Healthcare Can’t Pursue Fraud like Credit Card Companies. Here’s Why.

No, Healthcare Can’t Pursue Fraud like Credit Card Companies. Here’s Why.

For consumers, the credit card fraud prevention experience is seamless, which leaves many health payers wondering why they can’t access the same technology. The short answer? It’s complicated.

It’s easy to see how health payers, who have become disenchanted with promises by technology suppliers to “fix fraud,” find credit card fraud models alluring. As a consumer, it’s simple: Your credit card company keeps a record that identifies a specific purchasing behavior. Whenever there’s a deviation from that, the issue escalates and you receive a text along the lines of “[first name], did you just spend $XXXX at [store name]  in [location]?” Your simple “yes” or “no” response can either resolve or further escalate the issue and prevent further damage if your card has indeed been compromised.

“Credit card companies use a combination of technology and humanity to fight fraud, employing automated fraud detection algorithms across massive amounts of data collected from millions of customers and hundreds of millions of cards. Once a transaction is flagged as a possible problem, humans can follow up, contacting the customer. Even this is being increasingly automated, with some card holders receiving texts asking them to verify a suspicious transaction on their account.”

Source

We know as a health payer you hear it all the time: “Here’s the latest and greatest solution to hit the market! It’s going to drastically reduce fraud!” You’re a savvy consumer yourself, so any proposed solution is likely met with a healthy dose of skepticism. Still, you may see the benchmarks set by other industries and wonder, “Why can’t our health plan’s fraud solution be as effective as those offered by my credit card company?” 

It’s a great question and one worth asking, particularly as we see a bit of fallout from overused and overhyped tech buzzwords like “AI” and “machine learning.” But as an industry expert we work closely with explains, the reason healthcare fraud tactics differ from other industries, particularly finance, is complicated. That’s because healthcare is vastly more complex than the payment solutions industry. 

 

How Credit Card Fraud Analytics Work

As we described above, the consumer experience around capturing and preventing credit card fraud is perceived as easy and effective. But let’s look into the business aspect of how credit card companies manage fraud, which is generally a model that healthcare companies cannot directly follow. 

High false positive rates in your SIU would likely have you unnerved, but did you know the credit card industry averages an eye-popping 90% false positive rate? While your department’s high false positive rate may send costs soaring, the cost of such a high false positive rate for credit card companies is… hardly anything. Credit card companies are able to automate this activity and stay pretty hands-off because the analytics are simpler.

Health payers have vastly different variables to consider when analyzing healthcare fraud making it incredibly complex. So complex, in fact, that health plans will have a hard time ever moving away entirely from utilizing human intelligence to work claims. With so many factors at play, health technology’s true focus has to be putting forth better leads so that fraud analysts don’t waste their time pursuing red herrings. As many SIU leaders will tell you, technology solutions they see today are flagging claims that can easily be dismissed by human eyes. 

This blindspot is in large part due to a siloed approach and outdated technologies, according to ClarisHealth VP of Program Integrity Mark Isbitts. “It’s understandable that health payers are frustrated with current fraud solutions on the market today — they’re falling short and lack the robustness seen in other industries.”

Mastercard is entering the Health Fraud Detection space… is that a good thing?

The credit card giant has financial expertise, but can they embed themselves in the complex world of healthcare so easily? It looks like this development is, realistically, a technology that can plug into a larger more healthcare-specific fraud solution to power data security and more robust analytics, says Isbitts. 

Mastercard itself says that, in addition to security that is aimed at preventing data breaches, they “will also offer products aimed at using AI and machine learning to help payers curb fraud, waste and abuse, as well as predictive analytics to enable providers to use more effective billing strategies and improve their revenue cycle management. It’s an extension of similar products already offered to other industries, including major fast-food chains and large financial institutions.” 

As we’ve shown in this article, healthcare fraud is substantially more complex than the type of fraud that plagues financial institutions, and fraud as a whole is a smaller problem than waste and abuse. Still, improved analytical capabilities and a tightening of security is “a very good thing for the payer space,” says Isbitts. Read the article here

Why Fraud Detection is Harder for Healthcare

Health payers play a high-risk game if they allow too many false positives to trickle down into cases. While in the finance industry consumers aren’t typically bothered by credible inquiries into their spending patterns, providers on the other hand feel threatened by too many inquiries into claim legitimacy. As consumers, being checked up on by your credit card company makes you feel secure. Not the case in healthcare, where the already delicate balance payers have with providers can easily be thrown askew by a false allegation.

On the surface, using credit card fraud detection as a baseline works, say industry experts. However, though the model is correct, the challenge is looking at the underlying analytics, which are different. Unsupervised methods to track fraud in healthcare come at a high cost. Fraud scoring, as it’s termed, has to be determined differently in healthcare and currently, solutions are falling short both in terms of technology offered and the promises made.  

The current hit rate for advanced technologies is somewhere between 32-35%. Advanced technology, like machine learning and predictive analytics, can only work as well as the data that feeds it. Credit card fraud technology can work within simpler frameworks and run effectively with a high false positive rate all while boosting customer satisfaction. That’s not the case for healthcare. 

Consider this: if a health plan’s fraud detection solution looks at medical history and flags a probable FWA case, there are variables that AI logic may struggle with. Let’s say that a male visits an OB. Your fraud system may flag that claim as fraudulent, based on an isolated incident, without the ability to intelligently link a potential gender change from the medical record. Because of HIPAA and other factors, health plans cannot simply text a patient to ask them if this was a legitimate episode of care. 

Yet, there are ways that advanced technology solutions can overcome these perceived stop points. ClarisHealth is currently collaborating with a team of fraud analytics experts to develop a modern fraud detection solution that can be robust and effective for health plans. 

The Future of Fraud Detection for Payers

Advanced analytics is the future of healthcare fraud detection and prevention, but healthcare is complex enough that human expertise, intervention and detection is the gold standard. For a fraud solution to be effective, it has to take into account myriad data points and overcome data inconsistencies to persist in providing an investigator with a higher rate of accurate leads. We term this approach Total Payment Integrity and it’s essentially the ability to connect data points across platforms for single-source of truth. 

Payers’ short-term goal is to eliminate data silos and decrease case time for the SIU, both of which can be accomplished by reducing dependency on outdated processes. Also crucial is the ability to have clearer insights into details surrounding providers, who account for the majority of fraud cases. These details may include a better, more comprehensive understanding of a provider’s relationship with other practices and improved geographical metrics to quantify certain claims. 

An ideal — and achievable — fraud solution likely consists of a series of integrated data points with the application of advanced analytical concepts (AI) that look more comprehensively at information than current systems allow. To deliver this, health payers will need to be able to rely on a technology provider that is agile — someone who can develop dynamic solutions that stay abreast of modern schemes while also expanding basic functionality and improving “simple” shortcomings. 

Talk to ClarisHealth about how Pareo® comprehensive payment integrity technology is helping health plans deliver on their most advanced digital strategies.

Behind the Curtain: What to expect when you implement Pareo

Behind the Curtain: What to expect when you implement Pareo

Pareo is a unique platform that integrates with other software solutions to provide a comprehensive look at a health plan’s payment integrity processes. Here’s how we approach implementation of enterprise technology.

Just got word that your health plan is adopting Pareo® as a comprehensive payment integrity solution? Here, we pull back the curtain on what all goes into ensuring your health plan and Pareo work together in perfect harmony.

How We (All) Got Here

Our path to Pareo wasn’t all that different than yours. We started with a seemingly-unsolvable problem: How could we get a better view on everything we needed to see in order to effectively manage claims operations? With time, talent and industry expertise we developed a platform designed to transform payment integrity operations and shifted our focus to healthcare technology. 

We acknowledge that when you offer folks a solution they’ve never seen before, you have some educating to do. As such, here are some resources from our archives that touch on some of the steps leading to adoption and implementation of Pareo: 

Meet the Team

ClarisHealth has a team of experienced professionals dedicated to ensuring your Pareo implementation is a smooth transition. Leading the pre-Implementation team is Ric Stubblefield, Director of Implementations. Ric has overseen implementation of healthcare Software as a Service (SaaS) solutions like Pareo for nearly a decade, managing large teams of project managers and specialists while also serving as the main point of contact for clients during the process. 

At ClarisHealth, the Implementation team works closely with Product Support to guide clients through each stage of Implementation and ensure a seamless hand-off after the implementation project is complete. Our post-Implementation team lead is Yaw Agyemang, Director of Product Support. Yaw leads a team of product consultants who ensure that the functionality of Pareo meets the needs of our end users. He has decades of healthcare industry experience and has been a key contributor to shaping Pareo into the solution it is today. Yaw’s team serves as the ongoing point of contact for Pareo users. 

Why does this matter? As industry vets, we understand our clients and their frustrations because most of us have either been in your shoes or worked so closely to this industry that we know the long-running pain points you face. Under Ric and Yaw’s leadership, we’ve selected team members that are uniquely devoted to your success: 

    • Problem-solvers with a results-first focus
    • Industry experience
    • Clear communicators
    • Proven methodology with training every step of the way

Pareo Implementation in 7 Steps

Though we cater our implementation process to meet the needs of each individual client, our decades of experience have taught us to follow a seven-step process to guide each implementation project:

Project Kickoff

The Implementation team will review the statement of work (SOW) and develop a communication plan that establishes meeting and reporting cadences. At this stage, we will review the major components of each project and identify key deliverables. Known challenges are also acknowledged as our team prepares for discovery. 

Discovery

VP of Operations Kevin Jordan works closely with our Implementation teams in a discovery process that reviews workflows, user access (including role definition), reporting needs and process exceptions. During this phase, we also conduct a technical discovery. This includes the review of data file layouts, frequency of delivery and reviewing claim system integration requirements and file formats. This includes identifying vendor submission file formats.

Data Gathering

We conduct data gathering operations throughout the project. Initially, this phase consists of defining roles and rights for each user. Our team will also gather vendor details and load order, creating and reviewing sample reports. Data definitions are created as well as integration file formats. This is the stage when we begin communication with vendors and initiate training.

Configuration and Data Transfer

Configuration is dependant on the process workflows defined in the discovery phase, for both test and production environments. Clients can expect their reporting and dashboards to be created during this phase, configured and loaded into Pareo for review. As such, historical claim, provider and member data files are loaded and mapped. Custom fields are also tested and reviewed in this phase.

Testing

In the testing phase, we use sample vendor files and test all loading logic, review validation workflows and test claim system integration. Reports and dashboards, reviewed in the previous phase, are evaluated closely here for accuracy. Also, all user roles are security tested in this phase to ensure accurate access has been granted.

Client Sign-Off

In the test environment, once approved, the client signs off on the work that has been done. This triggers the creation of the production environment. Once the production environment is created, data migration occurs after which a final review is conducted before final sign-off in productions. 

Go-Live

The last leg of the process! During go-live, health plan and vendor production files are submitted into Pareo. Any issues found at this stage are actively managed by the Implementation team. Once resolved and when all parties agree that go-live is a success, the client is transitioned to the ClarisHealth customer success team! 

Average implementation projects last six to nine months, though this timeframe very much depends on a client’s needs and the SOW. As we implement Pareo at your organization, we have structured our process to include best practices allowing us to act in a secondary role as a software implementation consultant. This approach allows us to offer greater value to clients, who rely on us to lead them through this transition. 

This consultative mindset continues post-implementation. We have internal teams solely focused on developing education and other training tools and delivering those to clients in an ongoing manner to support engagement and utilization of Pareo. 

Talk to ClarisHealth about how Pareo® comprehensive payment integrity technology is helping health plans deliver on their most advanced digital strategies.

Why we focus on the problem, not the health care solution

Why we focus on the problem, not the health care solution

ClarisHealth CEO Jeff McNeese shares how our tech company created a solution born directly out of the frustrations with the healthcare industry, by experienced healthcare workers.

A major health plan client came to us recently and asked “Can you partner with us on this healthcare solution?” And it’s honestly one of the best compliments our organization can receive. Why? They know we understand their challenges as if we were working alongside them, and that puts us in a position of solving problems, allowing us to hit the ground running. This unique knowledge of health plan challenges proves useful when you’re evaluating potential technology partners. 

Consider a recent conversation we had with a health plan leader regarding advanced technology. The leader shared with us a frustration they had when approached by technology vendors who claimed to have a health care solution. But, this leader told us, when it came down to serious discussions, he often uncovered that the technology vendor knew a lot about tech but next to nothing about the industry, much less the problems facing it. 

Instead, the vendors in question wanted the health plan to tell them how to solve their problems. “We aren’t in the technology business, we are in the healthcare business. I don’t have the solutions. That’s why I’m coming to you!” the health plan leader recounted to us. 

This perspective has opened up a lot of dialogue for us internally around what it takes to be a good problem solver and why our experience matters so much. How are we able to, as one client told us recently, “see the problem as if you’re working alongside us”? With so many technology companies entering the advanced technology space, how clearly are they able to see the acute pain points facing the industry without having much healthcare experience? 

Good question. We know the problems that plague health payers because we’ve been in your shoes. Our company is a well-curated collection of folks from various walks of healthcare life: payer, provider and, of course, members and patients. Some of our team members, those in the Services department, are even working as Auditors, Data Miners and Overpayments Specialists — just like you. 

It’s our history and our commitment to deriving insights from the pain points these front-line employees bring to us, that allows us to be more effective problem solvers. And it’s not far fetched to admit that we love the problems — because that better positions us to solve them. Here’s what keeps us motivated to redefine the vision of technology in the health payer space. 

Problem-solving Mindset

We’ve been where you are today: stymied by processes that don’t work, and stuck in a situation where you are asked to deliver more with fewer resources. And, while we actively follow industry updates, including changes in compliance and legislation that are sure to affect our clients, perhaps more importantly, we listen. We seek opportunities to hear directly from industry leaders what works and what doesn’t in terms of technology solutions for payers. 

We aren’t the only technology company offering a solution by digging into the problem. Waze confounder Uri Levine says, “Fall in love with the problem not the solution, and the rest will follow.” When we can place ourselves in our clients’ shoes, we can see more clearly the pain points — big and small — that prevent health plans from managing payment integrity in an effective way. Understanding and accepting that the nature of problem solving has many ups and downs is something we embrace. 

Where does this love of problem solving come from? It starts with how we came to be a technology company. ClarisHealth was initially a services vendor. We grew frustrated by tools that didn’t serve our purposes, even simple things like automated time and date stamping on claims. This frustration triggered the development of what would become known as Pareo, a “nerve center” technology that integrates the varied data and viewpoints into a single source of truth. 

Today, health plans who are weary of outdated processes, of promises to help that fell short, of hearing the same rhetoric thrown their way, suddenly see the power of Pareo. And they get excited. Excited about the potential for transformation — moving away from what has become acceptable in this industry to what is possible. That excitement is contagious. It’s what keeps us going.

Here to Transform the Industry

Not everything about Pareo is sexy or glamorous. Imagine you had the best house in the world but the plumbing was not well done. It would quickly become a place you would not want to live in. Similarly, it may be cooler to throw out buzzwords like AI or Blockchain or NLP, but Pareo focuses on solving the real-world practical issues that prevent health plans from scaling a PI organization. We see Pareo as the plumbing, that foundational set of solutions, enabling PI leaders to build a fully integrated ecosystem where they can drive scale and efficiency.

The use of a design-thinking process helps ClarisHealth dig in and understand the problem, quickly model and deploy a solution. Through the years we’ve realized that it’s vital to ensure we are solving a big enough problem. It’s not our goal to offer yet another technology solution that is destined to become siloed. Rather, we want to elevate the whole industry

Our clients see this vision and through them, we are changing the way payment integrity processes are run. It’s the friendliest sort of disruption — from those in the trenches with payers, seeking to find a way through.

Focusing on health plan challenges is why we envisioned and built Pareo as a platform. Not only does it integrate seamlessly with many other best-in-class solutions, it’s also developed in a way that allows it to be continually tweaked and customized. In other words, we haven’t built a software and stuck it on a shelf. Our team is, at every stage of a project, creating a solution that meets the specific needs of a health plan. And what’s more, the various modules in Pareo get better and smarter as more health plans use them – a benefit that all of our clients feel in the way of continual updates. 

For those of you new to Pareo, we are glad you’re open to learning more about our transformative vision. And to those who have believed in us, thank you for continuing to support us and allowing us to take this dream of a better payment integrity solution — Total Payment Integrity — all the way to the top.

Talk to ClarisHealth about how Pareo® comprehensive payment integrity technology is helping health plans deliver on their most advanced digital strategies.

Time to get social! How to cover social determinants of health without increasing complexity

Time to get social! How to cover social determinants of health without increasing complexity

Payers are starting to go all-in on social determinants of health, but coordination of care can be complex. A look at how technology can manage these high-impact initiatives.

Already a trend for Medicaid, and now gaining steam among Medicare Advantage plans, payers are starting to go all-in on one set of initiatives designed to create healthier, less healthcare-dependent members: social determinants of health. Including everything from Apple watches to fresh food to GEDs, they’re meant to lower overall healthcare costs, but covering them can increase complexity for a health plan organization. How can health plans cover these potentially high-impact initiatives without increasing their administrative burden?

Social Determinants of Health (SDOH)

“Social determinants of health are the conditions in places where people live, learn, work and play that affect health risks and outcomes.” (PwC)

Coverage of Non-Health Initiatives

Social initiatives like pre-k programs, paid family leave, career training and wellness programs have traditionally been civic in nature. But in recent years, studies linking social determinants to health have caught the attention of health plans. The costs for non-health initiatives are less expensive than treating complex medical conditions, many of which could be prevented or mitigated by addressing social determinants of health. 

In 2018, the Kaiser Family Foundation published an article titled “Beyond Health Care: The Role of Social Determinants in Promoting Health and Health Equity.” In it, authors Samantha Artiga and Elizabeth Hinton explore social determinants and their impact on equal healthcare and outcomes. They identified how initiatives within the healthcare system have grown, noting that “19 states required Medicaid managed care plans to screen for and/or provide referrals for social needs in 2017, and a recent survey of Medicaid managed care plans found that almost all (91%) responding plans reported activities to address social determinants of health.”

The social needs that managed care organizations are required to respond to vary from state to state. For example, Arizona requires that community resources (such as housing and utility assistance) be coordinated under a managed long-term services and supports (MLTSS) contract. “When estimates show that more than 80% of all homeless people have at least one chronic health condition, investing in housing means this population can better focus on their care,” according to Dr. Derek Robinson, chief medical officer for Blue Cross and Blue Shield of Illinois. 

Other payer initiatives within the context of the healthcare delivery system look like meal delivery, adult day care, home safety improvements and even acupuncture and massage therapy, according to one study of five Medicare Advantage plans. Wearable fitness technology, like the Apple Watch, is starting to be covered by some plans. 

Why Payers Are Focusing on “Non-Healthcare”

Payers see the value in supporting SDOH, with some partnering to provide community resources that further their investment in non-healthcare initiatives. Last month, BlueShield of California announced a partnership with L.A. Care to open 14 wellness centers as part of a joint focus on community health.  

In May of this year, the Association for Community Affiliated Plans (ACAP) released a study determining the link between education and workforce development and better health outcomes and describing the “health impacts faced by Medicaid enrollees who are unable to obtain a job due to a lack of education or job skills.” 

Indeed, as funding for Medicaid is called in to question and an increasing number of states pursue 1115 waivers (which allow them to require work requirements for Medicaid coverage), it makes sense that health plans find ways to address education and career training for plan members. These programs include scholarship programs that allow recipients to pursue job certifications, personal coaching, mentorship programs and long-term employment opportunities. 

The ROI Question

There are financial incentives for health plans that expand SDOH coverage. New rules this year allow Medicare Advantage plans to get reimbursed for offering other supplemental benefits. “For 2019, CMS introduced new flexibility into the uniformity requirement by allowing MA plans to offer supplemental benefits to some—but not all—vulnerable enrollees,” writes C&M Health Law. This is a change from traditional interpretations of the regulation, which required supplemental benefits be primarily health related. 

Studies have emerged in recent years that highlight the financial return that implementing community health programs and SDOH interventions can offer. In July of this year, The Commonwealth Fund released an ROI tool that assists healthcare organizations in determining the financial benefits associated with SDOH to “help…plan sustainable financial arrangements to fund the delivery of social services to high-need, high-cost patients… who account for a large share of overall health care spending.” 

Some estimated savings highlighted by The Commonwealth Fund include estimates on housing initiatives, from which health plans may expect to save $1.57 for every $1 spent. “Although there is a growing literature confirming that community health programming can be effective for cutting down the high healthcare costs that often stem from limited social support, organizations still struggle with the payment piece,” reports Patient Engagement HIT

Payers addressing value-based care initiatives at their organizations may also be directly — or indirectly — looking at social determinants of health as a concurrent issue. It’s estimated that direct clinical care/intervention accounts for about 20% of healthiness, a relatively low impact. Improving outcomes and lowering costs requires casting a broader net. SDOH programs like care management models — which connect high-risk patients to necessary medical and non-medical community supports — have been found to reduce utilization rates, lower costs of care and produce significant ROI (July 2019, The Commonwealth Fund). 

Managing the Complexity of Meeting Social Needs

It’s easy to understand that managing SDOH is a complex issue. Solera Health and Blue Cross Blue Shield Institute announced this past March that they are piloting a program to coordinate regional patient resources with SDOH. As Solera founder Brenda Schmidt explained to FierceHealthcare, “There is no one-size-fits-all solution for healthcare or SDOH. Each individual has lifestyle/social needs that need to be met in a meaningful way, and member data allows Solera to match them to the right resource.” 

Anytime complexity is introduced into the healthcare delivery model, there’s a potential for fraud, waste and abuse. As health organizations weigh the benefits of addressing social determinants of health, they should evaluate if their technology resources are advanced enough to mitigate these risks. 

 

“There are many ways to ensure physical safety and care for loved ones. But what’s hardest to provide is everything that makes us human: joy, connection, meaning and enrichment.”

Joy Zhang, Mon Ami co-founder, as told to FierceHealthcare.

 

Advanced technology can enhance SDOH initiatives at health plans by increasing interoperability of real-time data. For example, predictive analytics can be used for personalized, data-driven decisions on member needs. Accurate return on investment for SDOH initiatives can also be determined. 

Additionally, the administrative burden of very complex contracts that expand supplemental benefits coverage is mitigated when claims are paid correctly (an easier task when plans have access to a robust technology solution). Payers aren’t the only stakeholders that are leveraging population health data. Metrics showing clinical care plays a small part (20%) in a patient’s overall care outcome and other imbalances which, according to some, indicate major mismanagement and an opportunity for disruption. “Consumer-focused companies are rapidly moving further into healthcare, and industry incumbents need to be ready for accelerating change,” reports FierceHealthcare.

Talk to ClarisHealth about how Pareo® comprehensive payment integrity technology is helping health plans deliver on their most advanced digital strategies.

Here’s What You Don’t Know about Fraud, Waste and Abuse

Here’s What You Don’t Know about Fraud, Waste and Abuse

Fraud is different from Waste and Abuse, and most technology solutions don’t adequately address either issue.

Think you know how to manage fraud, waste and abuse at your healthcare organization? CMS doesn’t agree. In fact, the promises of change and reform coming from CMS and GAO suggest that our government doesn’t feel that healthcare organizations are adequately managing fraud, waste and abuse at all. The data we have supports this. FWA estimates are in the billions, with the latest estimates pegging waste at 20-25% of healthcare spending.

Technology and services vendors who sell you components of fraud, waste and abuse management programs are doing you a small disservice if they market it as a total solution. They know as we do that, without system visibility, health plans and managed care organizations can only hope to control FWA – not eliminate it.

We aren’t suggesting that you shouldn’t work with technology vendors and third-party business partners – not at all. What we are saying, however, is that health plans need to do more than casually plug in a piece of technology or adjunct services with the hopes it will improve their FWA efforts. A more robust, proactive method is required to eradicate fraud, waste and abuse in your health organization.

The Confusion Surrounding “Overpayments”

By 2026, at least 7% of healthcare spending is expected to be made up of some sort of overpayments. That’s $400 billion – at least – and only 5% of that is expected to be recovered. But “overpayments” is a broad term that encompasses everything from mistakes to intentional fraud. Though fraud makes the headlines, the greater percentage of cases – and far costlier to the health plan – are incidents of waste and abuse. And they must be handled differently.

Going back to our earlier point, a health plan must be fully aware that programs to manage fraud, waste and abuse are only a piece of the puzzle. The key to gaining traction at your health plan is visibility. This is why CMS and GAO promote interoperability; they understand that with access to a broader picture (one that is accurate in real-time), you are less likely to get hung up in waste areas like administrative complexity.

What is your health plan doing about the 10% of inaccurately paid health claims?

Here’s how you can reduce FWA losses by 40% in one year.

We have explored the differences between fraud, waste and abuse in previous blog articles (here and here). To summarize, the primary difference between incorrect payments is intent. Fraud and abuse are categorized as illicit, but only fraud is recognized as willful. Together, fraud and abuse account for7% of healthcare spending. Waste, however, is excessive cost tied to administrative complexity, poor processes, paying costs to suppliers that are too high, and other wasteful spending practices. Clinical waste alone accounts for 14% of healthcare spending. But these are just examples to showcase the breadth of this problem.

In truth, there’s a lot that many health plans don’t know about fraud, waste and abuse – and it’s costing them millions.

“Fraud, waste and abuse is a huge contributor to unnecessary costs and the rise of spend within healthcare in the U.S.”

Forrester Research, 2019

What You Don’t Know About FWA – And How to Fix It

In order to fully solve the overpayment crisis in America – including fraud, waste and abuse – health organizations need to shine a light on the areas of this problem that remain uncovered. In 2016, CMS estimated the Medicaid improper payment rate at 10.5% or $36 billion.

A good FWA solution, integrated as part of a broader overpayment prevention program, should be able to make quick progress of identifying leakage at your healthcare organization. Here are 6 things you don’t know about FWA – and how to fix them:

Modern Fraud Solutions Combat Modern Schemes

The fragmented capabilities of most existing FWA solutions simply can’t keep up with the increasingly sophisticated schemes that keep emerging. Success is stymied by false positives, deeply hidden issues go undetected, and increasing time to detection and action prolongs losses. Advanced technology featuring predictive analytics promises to be able to analyze the massive amounts of healthcare data, flag likely fraud before it starts, and quickly build evidence needed to bring a case forward. When fully integrated across your health plan’s cost containment efforts, total payment integrity leverages all aspects of your PI program to bring insights that help increase savings, reduce redundancy and improve efficiencies and workflow.

Waste is Eliminated with Efficiency

Health Affairs defines waste as “spending that could be eliminated without harming consumers or reducing quality of care that people receive.” And wasteful spending, by some estimates, can amount to as much as one-third to one-half of all US healthcare spending. Administrative complexity shoulders the majority of the blame, and while it’s true that waste can be complex, the answer is more straightforward. Waste can be eliminated with efficiency. And efficiency is as much as mindset as it is a practice. Health plans that don’t focus on and achieve efficiency in their processes will struggle to combat FWA.

Waste and Abuse Outsize Fraud

Fraud is intentionally “playing the system” to erroneously benefit from it. It’s also rare, making up only 7% of healthcare spending when combined with abuse. But it’s easy for a health plan to be sold on the fear of fraud, perhaps leading to an overinvestment in technology that addresses fraud moreso than waste and abuse (which when combined far exceed fraud in the US). Health plans face increased audits from CMS, so it’s more important than ever to understand what percentage fraud, waste and abuse contribute to your health plan’s own payment rates.

Overpayments are the Bigger Issue

A report released three years ago by Harvard Business Review found that “even if the United States implemented all the approaches whose effectiveness had been measured, only 40% of the estimated $1 trillion of wasteful spending would be addressed, leaving a significant opportunity for innovation in all areas of health care.” The report estimates that innovations could reduce waste by $600 billion alone, presumably betting that healthcare (like many other industries) stands to benefit from technological improvements. Our takeaway from this report? A total payment integrity program must address more than FWA in order to maximize effectiveness. Innovations to reduce waste need to involve broader overpayment-prevention technologies.

Provider-Payer Partnerships Help Combat FWA

“Combating waste is an area that will require collaboration between employers, health plans, patients, and providers. The benefits are worth the effort: improving patient safety and reducing unnecessary health care costs,” writes Mercer US Health News. Working with providers in a meaningful way means treating the relationship as a partnership, one where both parties have a vested interest in resolving or preventing fraud, waste and abuse. In fact, improving this relationship is a top tactic for mitigating excessive prices, the number 2 culprit of waste at $231-241 billion per year. Tighter provider partnerships allow both parties to better tie prices to efficiency, outcomes and a fair profit. 

Reporting Should Be Ongoing – And Shared

Your health plan’s goal should be to transition efforts from post-pay to prevention. To that end, health plans should regularly measure certain metrics (Mercer recommends measures of misuse, over-use, and under-use be built in to provider contracts) but also share their findings. It may be helpful to share certain information with vendors, providers and staff from other departments. If information is shared more freely and interoperability is obtained, we can all benefit from the data that comes from payment integrity programs.

One Solution for All

You’ve likely heard the statistic that for every $1 spent on FWA investigations, more than $4 is recovered. What if you were able to take that investment even one step further? Pareo® was created to do something no other payment integrity solution can: plug in at multiple levels to provide health plans with the total system visibility that’s necessary for eliminating overpayment problems.

Our innovative technology combats wasteful spending by introducing more efficient processes for our clients. These accommodations include:

  • Unique differences by line of business
  • Integrated institutional and provider environment
  • Various payment methodologies: DRG, APC, ASC, per diem, fee schedule, percent of charge
  • Automated medical coding and billing

Talk to ClarisHealth about how Pareo® can transform your health plan’s payment integrity operations.

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