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.

More from Our Blog:

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...

Managing Medical Record Requests a problem? We’ve got the solution.

Managing Medical Record Requests a problem? We’ve got the solution.

How to manage medical record retrieval processes with multiple clinical audit vendors.Is your health plan missing out on the potential of having multiple clinical audit vendors because you’re concerned about overlapping medical record requests? That uncoordinated...

5 Keys to Help Your Health Plan Focus on 2020

5 Keys to Help Your Health Plan Focus on 2020

  No crystal ball needed. Here’s what we see successful health plans doing now to prepare for 2020. It seems like once Labor Day passes, we prepare for the last half of the year no matter what the weather does. Pumpkin everything, dreams of cooler weather and …...

Managing Medical Record Requests a problem? We’ve got the solution.

Managing Medical Record Requests a problem? We’ve got the solution.

How to manage medical record retrieval processes with multiple clinical audit vendors.

Is your health plan missing out on the potential of having multiple clinical audit vendors because you’re concerned about overlapping medical record requests? That uncoordinated approach to medical records retrieval is unnecessary in the modern age of vendor coordination and provider communications. 

For health plans that are ready to maximize their returns, improve recoveries and avoid the abrasion created by redundant medical record retrieval processes, Pareo® is your answer. Pareo is a comprehensive payment integrity solution that works by making data more accessible, connecting it to multiple stakeholders and managing real-time communications (including those related to the claims process and associated with technology vendors). With these efficiencies in place, health plans are able to maximize their recoveries by adding clinical audit vendors. Data is no longer siloed — it can be seen, used and leveraged by health plans. That’s the power of Pareo. 

Overlapping Medical Record Requests Begone

Suppose your health plan were to prioritize adding clinical audit vendors without a broader management tool in place. One of the very real side effects of this practice is overlapping medical record requests. It’s frustrating for everyone, especially providers who seek to prioritize patient care over cumbersome administrative processes. 

In instances where health plans have a lot to lose (recoveries, valuable providers, plan members), clear communication is crucial to success. We understand that our clients need to do more than just talk at stakeholders; they need to intelligently coordinate with vendors, providers and members in a streamlined but meaningful way. 

Unfortunately, some of the payers we speak with feel forced into an impossible decision: improve provider relationships OR recoveries. This approach, while understandable, is unnecessary. What if you could do both? What if expanding recoveries through adding vendors — a smart strategy for scaling health plan payment integrity operations — wasn’t stressful on providers? 

Harmony: Vendor Coordination + Provider Communications

By eliminating the fear of overlapping medical record requests, you are free to stack the best vendors to your advantage. Directing vendors to laser focus on their area of expertise creates more potential for finding anomalies; for example, having vendors concentrate on a line of business (e.g. Medicare Advantage, Medicaid, commercial). Data tells us that any time a health plan adds a vendor in a multi-pass capacity, their ability to increase recoveries improves dramatically. 

But don’t leave providers out of the loop. Health plans often run a planned series of audits that parallel those that a provider performs. With Pareo, each party can be on the same page about these audits; knowledge and understanding of them beforehand can minimize redundancies, says Healthcare Finance.  But as we all know, it’s not as simple as straightforward communication between a payer and a provider. Vendors are an important component as they rely on data to deliver results. 

Enter Pareo Clinical.

Pareo Clinical: Eliminates Risk Around Medical Record Requests + Retrievals

Tackle risk, reduce inefficiencies, increase nurse auditor throughput, improve your net promoter score (NPS) and increase recoveries with Pareo Clinical. Our solution provides gates and custom logic that streamline the medical records retrieval process to coordinate with vendors, eliminate duplicate requests and auto-route submissions to the appropriate auditor with smart tagging so nothing gets overlooked. 

To enhance communication, our solution creates a unilateral or bi-lateral portal of communication for our clients that allows them to not only communicate with vendors but with another very valuable player: providers. We understand that in today’s IT ecosystem, a true solution has to “speak” with multiple stakeholders in a way that removes redundant, wasteful processes. 

Those communications streamline activities that can be automated. But perhaps just as important, Pareo allows for sophisticated coordination between all stakeholders. With our technology, even pending requests — days outstanding, notes on interactions, etc. — can be tracked to prompt proper follow-up strategies. These efficiencies mean more clinical audit vendors and less abrasion with providers. In today’s world where health plans are being asked to do more with less, a scalable, comprehensive solution is the strongest way forward. 

Learn more about how Pareo supports health plans, providers and third-party vendors

Talk to ClarisHealth about how Pareo®advanced payment integrity technology is helping health plans stride confidently into an uncertain future.

5 Keys to Help Your Health Plan Focus on 2020

5 Keys to Help Your Health Plan Focus on 2020


No crystal ball needed. Here’s what we see successful health plans doing now to prepare for 2020.

It seems like once Labor Day passes, we prepare for the last half of the year no matter what the weather does. Pumpkin everything, dreams of cooler weather and … 2020 business planning. That’s pretty much what September will look like for many of us. This is the time of year when many organizations are thinking about the year ahead: making budgets and conducting strategic planning sessions. Where is your health plan heading, and are you looking far enough into the future?

Here are 5 key things health plans should consider as they plan for 2020. 

1. Start with last year’s plan

You’ve done this before — last year, in fact. There’s likely no need to reinvent the wheel as you plan for 2020 (though you may have some new ambitious goals). You can start preparing for next year by looking at your plan for this year and identifying what you know has worked and what hasn’t. Long-term planning in an industry that’s poised for disruption can be tricky, but we know there are a few persistent trends that can be addressed in your business plan:

2. Keep your long-term plans flexible

Disruption is knocking and plans that are inflexible won’t survive the future. You may not be able to plan for every specific change headed your way but you can plan for change. Flexibility is essential to ensuring the long-term plans you make are able to adapt to the coming changes in technology, business models and regulations. 

One business strategist says, “For any given uncertainty about the future — whether that’s risk, opportunity, or growth — we tend to think in the short- and long-term simultaneously.  I build a cone with four distinct categories: (1) tactics, (2) strategy, (3) vision, and (4) systems-level evolution.” Instead of a linear, timeline view — which perpetuates a cyclical tactic-strategy approach — a time horizons “cone” allows you to be more flexible, consistently poised to be ready for whatever the future brings.

3. Avoid the pitfalls of linear, short-term thinking

So, you can’t prepare for every aspect of the future. But that doesn’t mean you should avoid it. Short-term thinking can hinder long-term growth. Making decisions based on immediate needs will not serve you best moving forward. This particularly affects health plans when it comes to recoveries. Health plans may settle for less than what they could be getting because they are hesitant to invest in technology or expanding their vendor footprint because of cost. 

We understand this way of thinking; sometimes it feels like the only way to survive. But saving the tree, only to lose the forest is a mistake health plans can avoid. You may be able to get by with legacy technology and outdated processes for now, but investing capital in innovative technologies can set you up to thrive into the future. 

4. Prepare for innovation cycles

Deloitte’s paper The Health Plan of Tomorrow urges health plans to recognize and prepare for the coming disruption or “innovation cycles,” which they caution happen not all at once but often incrementally. Rather than wait for a huge sign, Deloitte advises health plans prepare now for “radical transformation” by: 

Transforming business models

“In the future, only plans that break down internal constraints holding them back will have survived,” cautions the paper. It’s important for leadership to accept and communicate impending transformation. 

Investing in dynamic technologies

It’s true, legacy technologies have held health plans back. Now’s the time to shift focus (and capital) to futuristic technologies such as: AI and analytics, automation, blockchain, and cloud computing. 

Workforce training and talent

Business transformation means employees will need to be trained in order to use new technologies efficiently. Furthermore, new talent will need to be acquired as new skill sets are required. To support these changes, health plans will be better served by shifting their workforce structure. “Data and analytics teams will no longer be housed within individual functions supporting only one market. Instead, they will sit across functions, feeding data from a multitude of sources to support care and claims teams.”

Dynamic data governance policies and practices

There’s going to be an enormous amount of data to manage in the future, and this requires a “strong data governance philosophy of data acquisition, management, and security,” says Deloitte. Our industry is working quickly to identify and agree on universal standards like Fast Healthcare Interoperability Resources (FHIR), but we aren’t quite there yet. Standards need to be flexible and able to quickly pivot based on new trends in order to survive in the future. 

Risk management

Health plans will rely more heavily on data in the future, which means the need for accurate data is vital. Risk always comes with new business models but in an industry undergoing disruption, it’s essential to closely monitor current risks and predict future ones. Paying attention to regulatory and compliance changes and accepting the evolutionary nature of such policies and plans will be key for health plans. 

5. Master these two skills essential to futurist planning

There are two interpersonal skills that translate well into futurist planning: learning to become a change agent and developing a community mindset. A change agent is “a leader who has the skills to navigate an organization through change management initiatives.” Understanding that change management may be a broader objective at your health plan, consider how equipping leadership with change agent skills may further your goals. 

Secondly, health plan leaders should embrace a community mindset. It’s time for health plans and other stakeholders (like providers and technology vendors) to come together and support one another on initiatives. Shared knowledge is a powerful component of community but there are also professional benefits in finding a support system. It’s easier to plan ahead for the future when we converse with other stakeholders regularly and can understand broader, universal challenges and opportunities facing our industry.

Talk to ClarisHealth about how Pareo®advanced payment integrity technology is helping health plans stride confidently into an uncertain future.

Be the change agent you wish to see at your health plan

Be the change agent you wish to see at your health plan

8 essential skills every change agent needs to navigate the future of healthcare

Whether you’re already leading change at your organization or hoping to do so soon, most health plan employees need to be well versed in change management as the industry braces for rapid innovation. Becoming an agent of change at your organization requires the type of holistic thinking that the healthcare industry notoriously struggles with. 

Based on our own experiences helping leading health plans implement change, here’s a look at how stakeholders can cultivate the 8 skills necessary to navigate the changing landscape, identify opportunities for innovation, and lead others into the future of healthcare. 

Change agent: a leader who has the skills to navigate an organization through change management initiatives

8 essential skills necessary to being a change agent:

1. Multigenerational influence

Unquestionably, health organizations successful in adopting change are embracing multigenerational influence in leadership (it’s even considered a competitive advantage). Representing all generations in leadership can help health plans respond to changes driven by upcoming generations, especially millennials

“The most successful companies will be the ones that let go of slow decision making processes and adopt a new talent base that is comfortable with experimentation, testing, learning — and even comfortable with failing,” writes Forbes. This cross-generational agility furthers a broader initiative of change management: culture. And culture is key to enacting true change says Becker’s Hospital Review.

2. Connecting change management to performance management

Healthcare has changed in scope and complexity in recent years, and reports indicate that errors – despite technology improvements – are on the rise. This leaves some to speculate that effective processes haven’t kept pace with rapid growth at health organizations. “The root cause of this organizational disease is not effort, but skill, specifically change management,” says Jim Molpus, Leadership Program Director at HealthLeaders. Molpus explains that in order to move the needle on change, leaders should embrace the facts when evaluating process vs. outcomes. 

3. Crisis management

Health plan leaders understand that reputation is important to consumers, but are we focusing enough on crisis management? In order to become the change agent your health organization needs, it’s vital to embrace the tenets of crisis management: communication, training, and preparedness. 

Leaders can train to proactively manage crisis by preparing for it. Organizations should implement a crisis management plan and incorporate it into change management initiatives. A focus on transparency can support crisis management. In Leading in a Crisis, authors Blair Sadler and Kevin Stewart posit that “leaders who promote and model transparent behaviors and instill a transparent culture in their organizations can use crises as learning and improvement opportunities.”

4. Appropriate technology training

Technology adoption can create stress and fear for employees, which is why it’s a good idea to for leaders to be fully trained in all necessary technology to guide easier changes in their organization. Hands on, ground-level encouragement can ease employees into higher usage rates. Keep in mind that change management requires constantly preparing for change – and technology is always improving. So technology training should be an ongoing, iterative process. Forbes Tech Council writes “it’s become impossible to separate business strategy from technological innovation.”

5. Insight into member satisfaction

To effectively lead change, we must be able to understand what drives member satisfaction. As more payers focus on member satisfaction, leadership should incorporate these initiatives into broader change management strategies. “While health plans generally are adept at managing the operational aspects of their business, a bigger challenge is addressing member expectations based on their experiences in other industries,” says HealthcareFinance

6. Awareness of new business models

Change agents should be aware of new business models – particularly evolving payment models and new technologies – that may affect the industry. According to a recent survey, about a third of health plan executives are bracing for major disruptions to business models. They believe that “new entrants, processes and technologies will upend current business models.” 

Anticipated areas of disruption include innovations in care delivery and refined member experience. Tracking proposed regulations and making other leaders aware of their potential impact is one way to ensure your organization can prepare for and quickly pivot as new business models arise. Payers may feel strained trying to anticipate and address every new business model, but they’re also poised to lead the change. 

“Health plans are in a unique position to drive innovation that will spread to each part of the healthcare ecosystem.”

Put on your cape. Your health plan may just save the healthcare system.

7. Entrepreneurial spirit

The willingness to take a risk and drive change is becoming an unwritten requirement for modern health leaders. This entrepreneurial spirit is marked by the following traits: 

  • Community-minded
  • Focused on advancement
  • Belief in oneself
  • Driven by “gut-feelings”

Being an entrepreneur is about “connecting the dots: those connection points of intelligence, wisdom, desire and ability that are innate to people,” writes Forbes. Though expected to find novel solutions and modernize, it’s difficult for health organizations to do so; the act of providing and delivering healthcare is different than the skills needed to drive growth through innovation. Entrepreneurial attitudes can prove particularly effective for health plans looking to bridge the gap and deliver change. 

8. Thought leadership

Connect with coworkers and establish yourself as an agent of change by embracing thought leadership, or the practice of becoming an informed opinion leader. In the age of social media, change agents can drive effective thought leadership through numerous channels. The practice of researching and informing others on industry-relevant topics can help leaders stay in-the-know on important topics as well as maintain impact and influence, while avoiding complacency

 “If leaders don’t feel comfortable with renewal and reinvention, they will begin to lose their impact and influence quickly.”



Power up with Pareo®

Talk to ClarisHealth about how Pareo advanced payment integrity technology is helping health plans successfully implement their digital-first strategies.

Prepare to Meet the Future with Data

Prepare to Meet the Future with Data

We revisit ONC’s Information Blocking Rule, recap public comments, and look at how health plans can meet data sharing  requirements.

Earlier this year, we wrote about the ONC’s proposed information blocking rule and how it serves as an opportunity for health plans. The proposed rule faced a public comment period (which closed last month) during which major industry concerns were voiced. The consensus by many seems to be that ONC’s rule lacks clarification in key areas while inadvertently increasing complexity (and cost) in others.  

But as they say, “the writing’s on the wall” for health data interoperability and broader access to electronic health information. Where does this leave health plans? A recent study by Deloitte predicts that healthcare organizations are standing at the precipice of innovation. But first, let’s look at the feedback that the proposed information blocking rule received.

Industry Response to the Information Blocking Rule

One thing we can agree on at this point: interoperability is a major objective for our industry. But those who would be affected by the Information Blocking Rule have asked the ONC to revise or even revoke the current rule. This includes the Federal Trade Commission, who despite being consulted on the proposed rule, issued a letter asking the ONC to consider refinements. Notably, eHealth Initiative (eHI) offered the following comments and concerns

Scope of “Electronic Health Information” is too broad, should be defined

Conditions and Maintenance of Certification (APIs)

      • Too complex and costly as proposed
      • Too much risk to providers and patients, specifically the proposed “Click Yes to Continue” model does not adequately portray data security risk to patient

Information Blocking

      • Healthcare actors should be defined in the final rule
      • Complex and costly documentation requirements

Greater Data Sharing is the Goal

The ONC has stated that greater interoperability is the goal of the proposed Information Blocking Rule. Improved data sharing is a worthy objective for health plans because it’s an easy effort to prove value on. Health plans have a competitive edge over their counterparts when they are more integrated with providers and members. In addition to priming plans to be compliant with whatever final rule is based, improving access to data is also key to readying for other initiatives, such as alternative payment models

Of course, we know that total healthcare data interoperability sounds like the answer to all your challenges. But once the hard work begins of solving this problem, it can feel like data sharing at the level required is next to impossible. We’re here to tell you it’s not; interoperability is a realistic goal with the right technology

Let’s frame the objective of the ONC’s Information Blocking Rule in a more approachable way: Healthcare stakeholders need real-time, accurate and contextual data access. And the real challenges? Healthcare organizations still struggle with interoperability, largely due to issues like administrative complexity. Messy (as in, unstructured) or missing data is still a problem as well. 

We know that our industry is on the precipice of innovation. The recent study from Deloitte referenced above and in our prior article posits healthcare is on the precipice of a “20 to 30 year industry transformation. The industry forces and the disruption that’s upon us are true indicators that we’re going to be going through a cycle of innovation.” Innovation made possible by radical data interoperability. 

ONC’s Information Blocking Rule has 7 exceptions. Do you know what they are?

See the official list here.

The Promise of Big Data

Improved access to data is considered a consumer-driven shift, one often compared to the Amazon experience where a consumer can have on-demand access to personal information. But getting personalized, real-time electronic health data at the click of a button is a lot more complicated than it sounds. And it requires a special relationship that has historically been difficult: high-level collaboration between payers and providers. 

Yet this demand is exactly the kind of opportunity health plans can seize upon as they search out competitive ways to utilize big data. Examples can be seen in the use of predictive analytics to mitigate risk, noted in this article as a “massive moneysaver” by one health plan who made a big IT investment. Reams of data are available to health plans — all that’s lacking is the right way to connect and analyze it. 

“Improving relationships with members and providers is already a focus for health plans, and data sharing is another way to accomplish that goal.”

Health plan of the future? It starts with data sharing.

One way of looking at the Information Blocking Rule is that it’s a proposed answer to a problem that health plans can take control of now. Improving data sharing isn’t just a proactive approach to anticipated regulation — it’s becoming an essential business function for health plans. To get started, health plans can focus on these three areas: 

Develop data analytics and predictive modeling know-how

Take advantage of opportunities to break down data silos by fostering relationships with providers, members and vendors

Look for existing technology that can support these goals: bring disparate data together, simplify data modeling, and provide a transparent communications platform

The future of data sharing is now. Pareo® is how.

Talk to ClarisHealth about how Pareo advanced payment integrity technology is helping health plans successfully implement their digital-first strategies. 

Can your tech do this? How to enhance your health plan members’ digital experience.

Can your tech do this? How to enhance your health plan members’ digital experience.

Health plans are shifting focus to ensure member satisfaction. Here’s how technology — even internal solutions — affect the digital experience of your health plan’s members.

Do you ever think about how different banking is now compared to 10, 20, 30 years ago? First came ATMs. Then debit cards. Then online banking. Today, if you step foot inside a bank, unless it’s for a high-trust/high-value conversation where only face-to-face will do, it’s a huge inconvenience. The world is filled with advanced technology and today’s consumers don’t care why healthcare lags behind. If the member experience you provide isn’t the seamless digital interaction they have come to expect, the next time they have a choice, will they choose you?

Health plans should focus now more than ever on the digital experience of their members to ensure satisfaction. Much like finance, the healthcare industry is becoming increasingly digital. Adding to that, many of your members are shouldering more healthcare costs than ever, which has them seeking clarity at the most granular levels. In a culture of choices, your health plan members are discerning clientele. 

Patients are Consumers

“Patients are increasingly becoming consumers because they have an increasing responsibility for the cost of their care,” writes Jonah Comstock. Statistically, you likely already know that member satisfaction is important because most of you are focusing on it. But what we can tell you is that regardless of a focus on digital experience, the big pillars of member satisfaction have not changed: service and value. 

Without nailing these basics, all the digital strategy in the world won’t help. Health plans are facing major shifts based on the consumer-focused mindset of the times. In short, your health plan member has choices now (and even those in group plans are being given more options by employers). 

Research shows that 42% of seniors prefer to shop for healthcare coverage online.


Basic customer service capabilities are part of the member-first focus shift at health plans. With the right focus on the tenets of member service, digital capabilities can augment them. When health plan members look for a good digital experience, that often means convenience, transparency and personalized communication. With the right technology, you can more easily satisfy these health plan member needs. 

Digital Experience Correlates to Member Satisfaction

While health plans have been citing an increased focus on the member experience, remember that doesn’t only mean the digital front door (e.g., health plan-to-member customer service-focused apps and portals). In a recent survey, 80% of Americans asked said they utilize online health information. 64% say they reference online provider reviews, and a quarter say they now use mobile tracking tools. 

The study’s author concludes, “Patient engagement in decision-making [is] associated with increased patient satisfaction and improved health outcomes.” For health plans, focusing on the digital experience of members is directly correlated with satisfaction. Create an experience that is highly engaging, and your member NPS is likely to be high (read more on measuring net promoter score [NPS] here).

While the correlation between an engaging digital experience and member satisfaction is clear, a new Forrester analysis says that only about half of health plan enrollees feel that their interactions with insurers are helpful. The analysis concludes, “Health insurers should take this into consideration when evaluating and adopting new digital customer service technologies like chatbots or real-time conversational guidance and analytics tools.”

What’s next? 

Any of your health plan’s internal processes and relationships with other stakeholders like providers and third-party service providers that could impact members are ripe for innovation. That level of comprehensive communication — with third-party suppliers, providers, and members — is exactly what ClarisHealth’s technology platform Pareo®is designed to offer. 

Talk to ClarisHealth about how Pareo advanced payment integrity technology is helping health plans successfully implement their digital-first strategies.