Lack of Documentation is a $23 Billion Overpayment Problem for Medicare

Lack of Documentation is a $23 Billion Overpayment Problem for Medicare

Medicare overpayment is a massive problem, and lack of documentation is a significant contributor.

When we see errors adding up to billions of dollars in improper payments, we pay attention. As payment integrity technology experts and also healthcare consumers we take notice when Medicare fee-for-service programs get slammed for $23 billion in improper payments due to documentation errors. More jaw dropping? Poor documentation processes cause 64% of improper payments in Medicare.

Let’s take a deeper look at how the problem of insufficient documentation became so huge and what you can reasonably do to address documentation errors at your health plan.We have considerable experience on the provider side of healthcare, and our interest in payment integrity is hyper-focused on automating some of the documentation processes required by the federal government.

Just How Big of a Problem are Medicare Overpayments?

When we discuss Medicare overpayment issues, it’s usually a million+ or billion-dollar problem. Recent headlines point to this fact:

CMS may overpay Medicare Advantage plans by billions, study finds

SUTTER HEALTH, AFFILIATES TO PAY BACK $30M FOR MEDICARE ADVANTAGE OVERPAYMENTS

$50 billion in Medicare waste? Yes, that’s how much in ‘improper payments’ are made per year

We’ve spent a considerable amount of time on our blog discussing fraud, waste and abuse and the role these elements play in improper payments. The problem is complex, and the solutions have to be agile and at-the-ready in order to be effective. According to Seto Bagdoyan, a director of audit services at the Government Accountability Office (GAO), of the “billion dollar a week” waste figures cited for 2017, $45 billion can be attributed to overpayments.

Some experts counter that the way HHS calculates waste is “weak,” and Medicare may actually have a larger problem than the already outsized figures making headlines. It’s hard to fathom the depths that Medicare waste truly runs, but being the problem solvers we are, we urge you to look at one sizable chunk of the problem: Improper Documentation.

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What is “Poor Documentation” and What Causes It?

If you can’t easily see the patient’s medical “story,” you’re likely looking at insufficient documentation.

Poor documentation has devastating impacts on patient care and is also a large driver of the improper payment problem. Health leaders attribute poor documentation problems to:

  • Busy Providers
  • Lack of specificity
  • Need for documentation education
  • Diluted content from “copy and paste” methodologies

CMS indicates that documentation needs to occur during or quickly following a patient visit and should follow the principles outlined in this document (which includes stating the rationale behind ancillary services or documenting in a way that makes the reason easily inferred).

 

“In fiscal year 2017, insufficient documentation comprised the majority of estimated FFS improper payments in Medicare and Medicaid, with 64 percent of Medicare and 57 percent of Medicaid improper payments due to insufficient documentation.” (source)

 

Most Overpayments Stem from Documentation Errors

Recently, the GAO reported in detail that overpayments in Medicare and Medicaid are mostly due to “insufficient documentation.” GAO figures the amount to be $23.2 billion for Medicare alone and $4.3 billion for Medicaid. CERT review criteria changed in 2009 and was attributed as a primary cause for discrepancies between FFS programs; Medicaid’s rate of insufficient documentation is only 1.3% while Medicare is over 6% on all claims.

The way medical reviews have been conducted is now being questioned, with the GAO citing the following four areas of difference:

  1. Face-to-face examinations
  2. Prior authorizations
  3. Signature requirements
  4. Documentation from referring physicians for referred services

The truth is, poor documentation is a problem we saw coming. We know that providers are busy, that their primary focus is serving patient needs, and that most EHR “solutions” are just more manual obligations for busy medical staff. Across the board, the ability to connect data between disparate systems is one that our industry has struggled to solve. That’s what makes Pareo® so unique. And with administrative complexity only growing, we’ve worked up a solution.

Pareo® Clinical: Our Hyper-focused Solution

Pareo® Clinical is the answer to streamlined workflows, a full document repository to support the audit findings, and the ability to develop more robust analytics that can be implemented earlier in your processes to catch documentation deficiencies before the payment goes out the door.

And if under-documentation is an ongoing problem with certain providers, Pareo® Provider can open up the lines of communication between payer and provider and offer education to mitigate that issue in the future. Providers want to submit clean claims, after all.

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

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The Value of Collaboration: Find Your Power

The Value of Collaboration: Find Your Power

Collaborative organizations — no matter the industry — are proven to be more effective. How can you tap into this mojo? Your health plan has working relationships with members of other departments, third-party payment integrity service suppliers and providers. By...

The Value of Collaboration: Find Your Power

The Value of Collaboration: Find Your Power

Collaborative organizations — no matter the industry — are proven to be more effective. How can you tap into this mojo?

Your health plan has working relationships with members of other departments, third-party payment integrity service suppliers and providers. By definition, that must mean you’re collaborating, right? Not so fast. Everyone working on their own — even if it’s toward a larger common goal — isn’t necessarily collaboration.

We’ll focus on our own organization, ClarisHealth, to look at how we collaborate internally and how our clients (health plans of all sizes) employ teamwork to transform PI operations. For us, effectively working together is crucial to our development process.

The What, Why and How of Collaboration

We recently wrote about how our software development teams follow iterative processes (which we feel is the best way to approach the needs of health plan technology). It would be impossible for us to succeed with Pareo® if we didn’t adhere to a mindset of collaboration at our organization. When I speak with leaders about what teamwork really is, I’ve learned that for some it simply means working toward a common goal. Collaboration is so much more than that!

What Collaboration Is and Isn’t

It’s cultural, relies on good communication and fosters innovation: collaboration is a top-level organizational approach to the way we manage employees. But collaboration isn’t simply a component of corporate culture (such as, offering more employee outings). We may use the word teamwork synonymously with collaboration but that doesn’t paint the broader picture. It’s a way of running an organization, and although collaboration can feel like a risk at some organizations (thought to promote activities that are viewed as inefficient or low-value) research tells us it isn’t any of those things.

 “Collaboration is not consensus. On the contrary, clarity about where the buck stops is one of the most critical enablers of efficient teamwork.” (source)

To effectively collaborate, employees need to be encouraged to work closely together in an environment where they can comfortably communicate thoughts. Leadership has to reward this type of behavior in order for it to spread. Once managed internally, your team can transfer collaborative work methods over to external stakeholders like third-party suppliers and providers.

Why Collaboration Should Be A Focus

All organizations stand to benefit from a focus on collaboration. In particular, those in the healthcare industry can take advantage of agile business practices that are typically adopted more slowly by these organizations. Doing so may give health plans a competitive edge, and health plans can realize real benefits:

    • Reduce administrative costs
    • Fast-track innovation
    • Improve working relationships

Collaboration is a culture initiative that has been shown to lead to business growth. In fact, multiple studies, such as this one, cite a majority of business leaders value collaboration at their organizations. In a modern workplace, we rely on collaborative communication tools like email, chat platforms, phones and other technologies in order to function. But to realize the growth benefits that collaboration brings, we must collaborate successfully.

How To Collaborate Successfully

So by now, we’ve identified two crucial elements needed for successful collaboration:

  1. Appropriate technology tools
  2. Top-level support

As we said above, your health plan is probably already using some tech-based collaboration tools for communication. But the high-level processes required by regulatory bodies (administrative complexity at its finest) require more sophisticated technology solutions.

We know that the best chance a health plan has to optimize recoveries is to collaborate more successfully with internal departments and with third-party suppliers (as well as providers). That’s why we developed Pareo®, a comprehensive payment integrity technology that allows you to effectively communicate both internally and externally. The key to successful collaborative technology is that it works — in real-time. Other, more limited solutions are rendered unusable in collaborative organizations.

Finding and implementing the right technology tools isn’t the only thing that will foster a collaborative environment at your health plan. You’ll need to embrace the culture of collaboration. Inc. offers some great tips:

  • Promote honest, transparent sharing
  • Create and use communication protocols
  • Have an ideation process in place
  • Require respect between employees
  • Reward and hold accountable

Successful collaboration is sure to contribute to realizing greater growth at your health plan. It has high-level impact potential for health plan operations. We know this because we’ve seen how, at our own company, the push for collaboration has made innovation possible. Our technology solution, Pareo®, is born of a highly collaborative and focused environment.

Bringing it Back to Health Plans: Collaborate

We think intentional collaboration is one of the key initiatives you can incorporate in 2019 to yield the greatest results – both intangible and financial. Collaboration at your health plan holds the key to inciting quick turnarounds at downward-trending operations. You can employ collaborative focus across the following key stakeholders to see results:

We’d love to tell you more about how Pareo® is designed to foster collaboration across your health plan, to internal and external stakeholders. Request a free proof of concept by emailing us here, or join one of our weekly demos: 

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

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Forget the Buzzwords. Lack of progress now doesn’t mean you’ll never catch up.

Forget the Buzzwords. Lack of progress now doesn’t mean you’ll never catch up.

3 practical steps you can take today if your health plan is feeling left behind on advanced payment integrity technology

A few weeks ago, a blog reader approached me about a recent article I wrote titled “Does Your Health Plan Even A.I.?” The reader, who also happens to be a director at a smaller health plan, said something to me that really struck a chord. She said, “Forget A.I. We’re still struggling to process all the requests that come in daily. There’s no way we can think about advanced technology like that right now.” And you know what? This reader isn’t alone. Her health plan isn’t the only one that, rather than facing a fear of missing out (FOMO, as my 8 year old tells me) they are fearful of falling behind.

Pareo® isn’t just for health plans who feel they are “ready” to be forward thinking. It was created to help you innovate, wherever you are in the payment integrity process. Imagine what plagues your PI processes the most, and that’s where we start. Just because something is labeled “advanced technology” or another industry buzzword doesn’t mean it is more difficult for you to use or implement.

You don’t have to be “caught up” when you seek out an advanced technology solution. Rather, you just have to know where to begin.

What’s really stopping you?

I’m going to detour for a moment, so stick with me. Have you ever put something off that’s beneficial because the time wasn’t right? “Sure,” you say, “I should go get that sleep study done, BUT I’ll wait until the kids are back in school or until this big project at work clears up.”

How often does the waiting actually pay off? Do you ever realize that if you’d just gotten the sleep study when your doctor recommended it, the help would’ve come sooner? Putting things off until the “time is right” very often just means that you have to wait longer for help to come.

We speak with health plans who have these same feelings, applied to payment integrity. They tell us “We’re too busy right now” or “We’re too behind” or even “We don’t need help.” And when it comes to advanced technology? “Sounds nice, but we’re struggling to use the technology we have,” they’ll say. But they also tell us that something isn’t working. It makes sense. Professionals all over feel like they’re falling behind, including athletes, marketers, and medical care providers.

 

“In what’s rapidly becoming a mobile-first business world, all manner of industries are being ‘shaken up’ by digital innovation.” Bryan Kirschner, director of the Apigee Institute

 

Start Gaining Traction

All these buzzwords are flying around and while they’re exciting, they’re also a bit nebulous. This feels especially true for health plans that are facing change on multiple fronts: reform, technology, workforce shortages and other external stressors. It’s understandable that when we throw around terms like AI, ML, Big Data, and NLP that health plans may feel overwhelmed — the healthcare industry is in the process of being disrupted.

Let’s look at three things you can do right now to start gaining traction in your payment integrity efforts:

1. Find the Best Next Step (and Take It)

The best advice on taking action when you feel overwhelmed is simply to start small. It never hurts to seek advice on this front from a trusted resource (we are always happy to help). For instance, you may benefit by performing an “audit” of your current payment integrity operations.

2. Set a Goal for Advanced Technology Integration

Now is not the time for everyone to embrace artificial intelligence, machine learning, and more — and that’s ok. But change is on the horizon, and your best bet is to set a goal to implement some form of advanced technology into your payment integrity operations. Health plans need to continue to focus on data sharing and their ability to comply with regulations requiring interoperability. Pareo®, while equipped with advanced technology, seeks to support data sharing goals at organizations through comprehensive access to information.

3. Power Through Feeling “Stuck”

When you fear you’re falling behind, there’s no need to feel discouraged. If you get stuck along the way, ask yourself if what you are experiencing is physical or psychological (called “paralysis by analysis”). In addition to structural roadblocks like lack of resources, other common barriers to advancement are rooted in emotions like fear. (Symptoms include pesky internal dialogue featuring “should have done …” and “what if …”) Stepping outside of the problem to gain insight into what’s causing your PI operations to fall short is a powerful way to power through problems. Additionally, transparency can be a key tool for health plans that feel stuck.

ClarisHealth seeks to be your partner in total payment integrity, so remember: you don’t have to go it alone. And while we do offer an advanced technology solution, we aren’t robots. We’re real people, passionate about helping your health plan find its focus, increase recoveries, and get ahead of the curve in this increasingly complex industry.

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

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Burned out and Bored? Remind Your Employees Why Payment Integrity Matters

Burned out and Bored? Remind Your Employees Why Payment Integrity Matters

Address the “why” behind payment integrity and you’ll find that health plan employees no longer feel stuck.

Most talented employees start out in their jobs with a great deal of optimism: meeting new people, learning new things, looking forward to making a positive impact. Seeking to challenge and be challenged and grow within the role and future roles. What if, instead, every day they are faced with challenges they can’t surmount by working and thinking harder? What if they are surrounded by people who, in the face of such odds, have given up on that situation ever improving?

It can be really demoralizing to feel like you’re not progressing toward your goals. At health plans, where payment integrity system processes have remained largely unchanged for 20+ years, this type of burnout and disengagement is a real risk.

 

Our ‘why’ is helping you get excited about payment integrity. Pareo® can free you to do the job you set out to do: innovating, instead of battling barrier after barrier.

 

Is Your PI Team Suffering from Burn- or Bore-Out?

We’ve all been there — frustrated by redundant processes, tired of the same ineffective workflows, or just bored because you’re doing work that is manual (when it could be automated). How does this affect payment integrity processes? Employees who suffer from burn-out or bore-out don’t have the tools or stimulation they need to contribute as much as they once did, even if they’re working in their dream career.

 

“Actively disengaged employees cost U.S. companies between $450 – $550 billion in lost productivity per year.” That’s at least $14,000 per second. (source)

 

Burn-out, or feeling disengaged from your work to the point of stagnation, differs from bore-out which refers to extreme boredom at work (a signal that an employee isn’t challenged enough). Both conditions stem from repetitive processes and are heightened when employees cannot effectively do their jobs. Overwork can further amplify employees who are feeling burned out or bored. And in the healthcare industry, where we all are asked to “do more with less” and shepherd wearisome administrative processes, chances are your PI department is burned out.

 

Discomfort is a hallmark of technology changes, but it’s also a cure for employee burn-out. Challenging what you think you know is a healthy work process.

 

Health plans should gauge employee engagement and productivity in order to determine if burn-out is occurring. Due to high costs of productivity losses and the demands of the healthcare industry, you simply cannot afford to allow burn-out and bore-out to persist. Furthermore, combating burn-out can be as simple as reminding your staff “why” what they do matters.

Modernizing payment integrity is a huge opportunity, one that Pareo® helps your team manage. Arming your payment integrity department with the reasons to move forward and the right tools is a powerful cure for burn- and bore-out.

The Why Behind Pareo — and Why It Matters

Schedule a demo or meet with us in person and it won’t take long before you notice: ClarisHealth is full of passionate people. It stands out  in an industry that seems a little “stuck.” Our company was founded after years of working in payment integrity, years that informed our belief that technology could revolutionize the industry. Inevitably, we came to the conclusion that health plans (and providers) simply cannot do what they need to in the dark.

We felt compelled to shine a light on outdated processes and transform payment integrity. The reams of data that are collected by healthcare organizations are only useful if you can, well, use them. Many of us at ClarisHealth have been right where your employees are — met with lots of demands but ill-equipped to meet them.

That’s why we understand the problems your health plan faces, and why we feel confident that we can help you solve them.

Beat Burn-out with Innovation

An innovation partner like ClarisHealth does more than just enable you to grow recoveries (though we’re pretty great at that). We view our relationships with clients as a commitment to growth and innovation. We partner with you to solve the problems that have plagued your health plan for decades. If this sounds exciting, that’s because it is. We’ve had clients say that our solution is like nothing else they’ve ever encountered before.

 

“Pareo® was unlike anything on the market. It was the only comprehensive payment integrity platform that covered all the bases. It also comes with highly valued functionality like a medical records repository and a robust analytics suite that will enable us to internalize more of our payment integrity operation.  The team at ClarisHealth has a very deep knowledge of the payment integrity market and it shows in the product they have built.” Senior Manager of Payment Integrity, State Health Plan

 

Your PI team will be enthused to learn that a real, powerful solution — a people-centric solution — is available from ClarisHealth. Burn-out can be transformed into passion with the right tools. Our payment integrity solution offers:

    • Clear processes
    • Meaningful data to impact results
    • Elimination of silos and other barriers that hinder progress

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

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ClarisHealth Achieves HITRUST CSF® Certification to Manage Risk, Improve Security Posture and Meet Compliance Requirements

ClarisHealth Achieves HITRUST CSF® Certification to Manage Risk, Improve Security Posture and Meet Compliance Requirements

HITRUST CSF Certification validates ClarisHealth is committed to meeting key regulations and protecting sensitive information.

NASHVILLE, Tenn., April 17, 2019 – ClarisHealth, a leading provider of advanced payment integrity technology for health plans, today announced its solution Pareo® and supporting infrastructure has earned Certified status for information security by HITRUST.

HITRUST CSF Certified status demonstrates that the organization’s payment integrity solution Pareo® has met key regulatory requirements and industry-defined requirements and is appropriately managing risk. This achievement places ClarisHealth in an elite group of organizations worldwide that have earned this certification.

“ClarisHealth is committed to achieving the highest levels of data security and regulatory compliance with respect to sensitive healthcare information,” says Jim Weathersby, chief technology officer for ClarisHealth. “Nowhere is this more evident than our achievement of the HITRUST CSF Certification. This certification is the gold standard when it comes to sensitive information protection and we are very pleased to offer this added level of assurance for our customers.”

By including federal and state regulations, standards and frameworks, and incorporating a risk-based approach, the HITRUST CSF helps organizations address these challenges through a comprehensive and flexible framework of prescriptive and scalable security controls.

“HITRUST has been working with the industry to ensure the appropriate information protection requirements are met when sensitive information is accessed or stored in a cloud environment. By taking the steps necessary to obtain HITRUST CSF Certified status, ClarisHealth is distinguished as an organization that people can count on to keep their information safe,” said Ken Vander Wal, Chief Compliance Officer, HITRUST.

About ClarisHealth

ClarisHealth is the answer to the health plan industry’s siloed solutions and traditional models for identification and overpayment recovery services. We provide health plans and payers with total visibility into payment integrity operations through our advanced cost containment technology Pareo®. Pareo®enables health plans to maximize avoidance and recoveries at the most optimized cost for a 10x return on their software investment. 

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

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Can your self-built technology solution do this? Why iterative software development is essential.

Can your self-built technology solution do this? Why iterative software development is essential.

Health plans considering self-developed payment integrity technology should ask themselves: Do we have the resources to be agile?

Iterative Software Development: A cyclical method of software development which focuses on improvements based on continual revisions and upgrades. User feedback is utilized to ensure that the software solution is successful.

In 2018, we released 33 updates to our payment integrity technology Pareo®, improvements that came directly from user feedback. Fast and flexible software development is essential in today’s digital market, which begs the question: can in-house developed software really be iterative?

It’s hard to imagine that a health plan is maximizing their resources by adding “software developer” to their byline. The more sophisticated elements of creating tech solutions — like iterative development models and Scrum processes — come by way of having the time, talent, and drive to focus on them.

Pareo® is especially attentive to user feedback, and it’s not just to make our clients feel “heard” (though that’s important, too!). We utilize the feedback that your team gives to proactively create solutions to problems before they fully surface.

Stages of Software Development

In order to effectively develop a solution to complex problems, software development follows a set process. This process consists of the following steps:

  1. Planning
  2. Designing Project Frameworks
  3. Development and Programming
  4. Testing
  5. Deployment

Software has a life cycle, termed SDLC (Software Development Life Cycle), that begins with planning and ends when a technology product is removed from the market. SDLC has many models, which include: Waterfall, Iterative, Spiral, Agile, and V-Shaped. Of these defined models, iterative is the most appropriate for large-scale development projects that need to remain flexible and responsive to varied conditions like regulations and multiple stakeholder requirements.

Iterative software development is an answer to the outdated processes that keep holding our industry back. In iterative models of SDLC, technology vendors are constantly improving aspects of their technology solution in a way that maximizes scalability but minimizes any total system downtime.

Why You Should Ask Third-Party Tech Vendors If They’re Iterative

Think understanding how software is developed and what model is utilized is too “in the weeds” for your health plan? On the contrary, these questions are essential to discovering how a tech vendor operates and how scalable a solution they are producing.

If the payment integrity technology vendor you are evaluating can’t speak to process and SDLC models, you can quickly rule them out. You’ll also be able to determine how quickly an update may come down the pipeline. Agile development produces constant updates, whereas traditional on-premise solutions are updated 1x-2x a year. Self-developed technology may never be updated.

Pareo® relies on an iterative development model because it works well in our industry. The flow of iterative development is circular, and works by repeatedly testing our technology solution to make sure it best serves its purpose. By soliciting user feedback and analyzing user behavior, we continue to work on solutions for clients that stay ahead of the curve. Additionally, this method of development allows us to consider what regulations and changes need to be incorporated into Pareo® to ensure it is functioning as a true agile solution.

How User Feedback Shapes Pareo®

When technology solutions don’t engage the end-user during development, what’s left is often an abandoned “solution” that’s left behind because it no longer meets the needs of the user. But as others have pointed out, you can’t simply ask a user if they like your product. Rather, you have to ask a series of strategic questions that solicit meaningful feedback.

When we partner with you, we partner with your associates.

The concept of a Net Promoter Score, or, learning how likely a client is to refer your product/services is extremely useful for software development. Asking additional probing questions such as “What problems do you encounter?” and “Are you satisfied with the level of customer support you receive?” are even better ways to solicit user feedback.

ClarisHealth not only captures this kind of data from our clients, but we also analyze how users engage with Pareo®. In particular, we like to look at which parts of Pareo® are utilized (and which are not). Sometimes, we learn new ways of utilizing Pareo® from user behavior! This two-pronged approach allows us to create a dynamic, fluid technology solution that users can effectively leverage in order to better do their jobs and improve efficiency.

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

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The Value of Collaboration: Find Your Power

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