Modernizing communication with providers

Modernizing communication with providers

Time to move past playing telephone with providers. Here’s a better communication strategy for health plans. 

By relying on fax machines and snail mail to communicate overpayments, underpayments, denials, and just about everything else, the payer-provider relationship sometimes looks like very dysfunctional pen pals. The cost of managing this unwieldy process is too high for both parties, but new options for electronically communicating are emerging. Here’s a candid look at how your health plan can modernize its approach to provider communication. 

What solutions have been proposed to improve payer-provider communication?

Remember the grade-school game of telephone? You sit in a circle and pass a message around by whispering it into the ear of the person next to you. Then the last person has to say to the group what they heard and often, the message varies hilariously from the original. What’s been happening between payers and providers isn’t all that different, only it’s not very funny. 

There are real costs and consequences associated with poor communication. And besides, moving away from telephone conversations is considered a first-step solution to improve provider communication. So what’s replacing phones and fax machines?

Two solutions have emerged as leaders in the effort to improve traditional communication problems: the Blue Button initiative and electronic payer-provider portals. Each is complex in its own right but are summarized below: 

    • The Blue Button initiative was introduced last year and aims to provide greater access to claims data. Several ONC/CMS proposals have been issued to promote health data sharing, more broadly, across healthcare organizations. These initiatives tend to be more focused on healthcare point-of-care decisions, though, rather than getting paid. Recently, CMS announced the Medicare Blue Button, a pilot program planned for launch next month. Other data sharing initiatives involving APIs have also been recently announced. 
    • Electronic payer-provider portals are solutions more focused on communicating about claims: overpayments, underpayments, denials, prior authorizations, medical records documentation. Last year, CMS administrator Seema Verma stated she wants physician fax machines gone by 2020, replaced by digital health information exchange. But to be effective, digital health information available via portals should be all-electronic, real-time communication in order to truly drive engagement and efficiencies.

What’s clear is that outdated methods of communicating between payers and providers will no longer suffice, either due to regulation or market demand. Furthermore, in order to meet consumer demand, payers and providers have to find a better way to share data. 

“People die because we don’t provide access to data in a real-time basis. The most important thing we can do is figure out how to coordinate that care in real-time so we can directly impact and save lives,” says a leading Blues plan president and CEO.

Where does Pareo® fit in? 

Pareo is a technology solution for health plans that fosters improved communication with providers through native, built-in tools. By automating some communication needs, streamlining others, and eliminating errant messages entirely (such as duplicate medical requests), Pareo allows health plans to make strides in digitizing health communications with providers. Importantly, a communication and engagement module like ours can serve to bridge the gap between data sharing and actually getting paid (something payers and providers alike appreciate). 

Pareo enhances Provider Communication efforts through: 

  • Faster payments with less manual intervention
  • Improving trust/NPS with providers
  • Facilitating alternative payment models
  • Growing recoveries

Payers need a way to see the bigger picture — a way to aggregate data and make informed decisions quickly. With an electronic provider communication mechanism in place (like Pareo), data sharing initiatives like Blue Button and APIs become actionable ways to move the needle and, even more importantly, save lives.

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

What makes value-based care programs work? 3 keys to success

What makes value-based care programs work? 3 keys to success


Following up on our previous article, we look more closely at what successful value-based care initiatives have in common.

It’s not all that surprising that one of our recent blog posts, Medicare for All: Should it be feared by health plans? has quickly become one of our most popular. Value-based care programs, like what the federal government has switched to, are at the forefront of discussions regarding the future of healthcare. And a recent survey indicates that providers are actually willing to take on more risk under alternative payment models, which signals well for value-based care adoption. 

But it takes awhile to implement value-based care programs and that may leave many health plans wondering what they can do to be proactive. Here are 3 strategic initiatives your health plan can pursue today to ensure value-based care programs will be successful on down the road. 

1. Communication

We’ve talked a lot lately on the blog about communication and collaboration and with good reason: the future of healthcare demands it. As care models shift, the need to work effectively with other vested parties is paramount. 

Take for example a recent panel in which industry experts (18 in all) were asked to define the term “value-based care.” While the term “value-based payment” was broadly agreed on, experts could not come to a consensus on the meaning of value-based care reports FierceHealthcare. “In addition to these specific gaps in communication, the study highlighted just how valuable it can be for industry leaders to convene with others who may not share the same perspective,” says Meredith Williams, M.D.

Health plans can prepare for  value-based care by fostering better communication with internal and external stakeholders. As Williams points out above, sitting down with other experts in the industry to get on the same page is a powerful — and unprecedented — move. 

2. Transparency

Alongside value-based care runs another initiative: transparency. Real-time access to crucial medical details, patient access to data, and upfront pricing are goals associated with successful value-based care programs. 

True transparency is only possible when health organizations have a firm grasp on data. Yet interoperability remains a struggle: 74% of respondents in this survey list the “ability to aggregate and share information as an extremely important need over the next three years.” By 2020, 59% of healthcare payments will be from value-based care models, and that means health plans need to work now on integrative data strategies. 

A shift towards transparent practices can directly affect your health plan’s relationship with providers. The ability to collaborate with elements of the healthcare trifecta (patient, provider and payer) will grow increasingly important for health plans seeking to thrive in a value-based care environment. “If value-based care is about aligning what works best for the patient to a hospital’s financial incentives, then insurers and providers must work together to create the best outcomes,” writes Healthcare Finance

3. Technology

With communication and transparency as actionable goals for health plans seeking to prepare for value-based care, technology is a third and crucial piece of the puzzle. With the right technology solution, health plans can improve communication and engagement with key stakeholders while promoting more transparent data practices. “Data is much easier to connect with when you are able to see it in real-time,” notes Jason Medlin, ClarisHealth VP of Marketing & Business Development. 

Investing in IT and technology to foster innovation was a featured conclusion of the Deloitte report “The Health Plan of Tomorrow.” Switching from volume to value in healthcare models will require a sophisticated technology strategy. The goals of value-based care programs — largely focused on access to patient care data — are not currently achievable at many health plans. 

The fastest way to transform? Technology, says Healthcare Finance. A comprehensive payment integrity solution should also provide a way of interpreting big data to transfer into actionable insights. “Once an organization has its data and is able to analyze it, it can then pinpoint opportunities for changing the practice to improve efficiencies without compromising quality outcomes — and for improving patient care overall.”

The Healthcare Trifecta Matters More Than Ever

Payers, providers and patients make up what we refer to as the “healthcare trifecta,” and the effectiveness of this relationship directly correlates with the success of value-based care models. Even as payers and providers work towards improved collaboration and communication, health plan members also  seek more ready access to information. Health plans who focus on supporting and improving their relationships with providers and patients are poised to adopt value-based care more successfully.

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

Medicare for All: Should It Be Feared by Health Plans?

Medicare for All: Should It Be Feared by Health Plans?

Worried about “Medicare for All”? You certainly aren’t alone, but health plans could view this as an opportunity. 6 Myths and facts revealed.  

Proposals for single-payer healthcare models — sometimes termed “Medicare for All” — top today’s healthcare news. Strong opinions abound and Medicare for All is riding a wave of popularity now due to rising healthcare costs and those impacts on the consumer. None of us have any idea if it will happen or not, but if it does, there are some common misconceptions about if or how it would work, particularly from a health plan perspective. Let’s take a look at six of these prevalent fears and their potential impact.

1. MYTH: Medicare for All would erase profitability in healthcare.

Getting to the heart of the matter, many health plans are concerned that broader access to Medicare would reduce their profits. Is it true that government-assisted healthcare programs are less profitable than others? According to Susan Morse, Senior Editor at Healthcare Finance, health insurances would lose profitability in the marketplace, but others contest the validity of this statement.

One analyst notes that what we term “single-payer” is a bit misleading, as Medicare resembles multi-payer health care models the world over. Indeed, Medicare Advantage depends on a large number of private insurers to work and this is unlikely to change — especially given the unforeseen profitability of the Medicare Advantage marketplace after the Affordable Care Act. CMS anticipated a 12% increase in Medicare Advantage enrollees in the 2019 Open Enrollment season, many of whom will “likely find lower or no premiums and improved benefits,” according to officials.

Fact: In reality, Medicare Advantage plans have been some of the most profitable sectors for health plans.

Faced with treating uninsured or underinsured patients, providers are actually better off treating those who are covered by Medicare or Medicaid. High out-of-pocket costs can be hard to chase down.

2. MYTH: Sudden access to healthcare coverage by some segments of the population (the uninsured and underinsured) would create too much risk.

Risk of uncertainty is something that many health plans fear will increase costs and become a potential unintended consequence of Medicare for All. To evaluate if this is as large a threat as it may seem, it may be helpful to look at how profitability has soared under the Affordable Care Act despite a sicker risk pool. In 2017, medical loss ratios were down to 70% (a stark decrease from 2015 when they reached over 100%). Insurers raised premiums to correct the market and reflect risk, but researchers say that increased profits indicate the risk was more than covered. This means that the market has been able to correct for risk and has perhaps overcorrected already.

 “Most providers would prefer to treat an insured patient whose plan pays closer to Medicare rates than to treat an uninsured patient, so their bottom lines would still benefit if more uninsured people enroll in the plans.” (source)

Fact: Uncertainty already exists in the healthcare market, and value-based care is seen as a way to offset any potential increased market risk by increasing access to lower cost, preventive care.

Delaying medical care can actually prove more costly in the long run, and it’s exactly the kind of position that those without access to good health coverage find themselves in. The Federal Government reports that those without access to healthcare are more likely to die prematurely and less likely to receive a medical cure. Once they do receive access to health care, medical conditions may have worsened to necessitate a more costly treatment.

On the flip side, recently-released research in JAMA Cardiology shows a positive effect on “population-level differences in rates of cardiovascular mortality among states that expanded Medicaid under the ACA.” Broader access to healthcare works for all of us. 

3. MYTH: There’d be no more private insurance.

With broader access to affordable healthcare proposed by “Medicare for All,” payers worry that the more profitable private insurance market would disappear.

In other countries where healthcare is offered at little or no cost — such as England — the private insurance market continues to thrive. Multi-payer markets include private insurance options and furthermore, Medicare is seen by many analysts as a multi-payer market already (one that’s working).

 FACT: Elimination of private insurance is highly unlikely.

 Moreover, the move to broader healthcare coverage is a market opportunity for health plans to improve customer service. We know that more is required by health plans regarding patient information access to data and that member satisfaction is a key focus for payers. Medicare for All could be a strategic opportunity for health plans to support the patient-centered focus already underway in this industry.

4. MYTH: With broader access to healthcare, there will be a run on healthcare services, creating shortages.

If everyone suddenly has access to healthcare, will it be harder than ever to find care — let alone, quality care? Let’s look at what happens in our country when senior citizens gain access to Medicare. Do they “overuse” healthcare because they think it’s “free”? Of course not. Additionally, the concern exists that fewer and fewer people will want to become doctors if their pay is significantly reduced; nearly half of doctors are concerned about pay cuts if a single-payer system came to fruition.

FACT: Healthcare is not an expendable resource. Furthermore, value-based initiatives are focused on streamlining care through prevention and increased “self-service” (like telemedicine).

It’s true that with broader access to healthcare, our old care models will need to change. But with wasteful healthcare costs on the rise, it seems the industry will be shaken up whether access broadens or not. “Well over half of Americans already say they have a favorable view of Medicare for All. Though approval falls off when confronted with details such as higher taxes, it is clear that the electorate is searching for something big,” writes Elisabeth Rosenthal for Kaiser Health News.

5. MYTH: This model would create unprecedented complexity in healthcare.

This one is admittedly, a little tough to imagine for us given our line of work. We see unimaginable amounts of complexity in healthcare, and we actively work to manage complex processes for our clients through our payment integrity technology solution.

It’s bold for some to tout complexity as a con of Medicare for All; it would be hard to get more complex than the industry already is. However, it’s worth noting that analysts  advise that judging a single-payer program’s viability on Medicare or the ACA just doesn’t add up. It’s also over-simplifying matters to reduce Medicare for All to an expansion on current Medicare benefits, though it’s tempting to do so (especially during the upcoming primary season). With various proposals on the table, ranging from lowering Medicare’s qualification age to 55 to a full-on single-payer system, it seems that there’s still a lot to work out.

FACT: Greater standardization is now mandated by the government. This is the first wave in an all-out war on complexity, one that Medicare for All would likely benefit from.

6. MYTH: Medicare for all won’t work… because we’ve never done it before.

Is failure a sure bet? I think we all know the old saying “The best laid plans of mice and men often go awry,” and certainly rolling out a program like Medicare for All would come with its own kind of challenges. But the idea that broad access to healthcare is new is false. Western countries have implemented some version of broad healthcare access for decades — mostly to positive reviews.

FACT: Medicare and Medicaid coexist relatively successfully. This disproves the claim that another healthcare program would “sink the ship.”

 It’s hard to say with any certainty what the future of healthcare in the country looks like, but one thing IS for sure: change is inevitable. The old system just isn’t working anymore.

Bottom Line: Costs are going up, for health plans and their members.

Single-payer proposals are gaining traction for a reason. This environment provides a prime opportunity for health plans to embrace the conversation surrounding health plan options. Offering solutions around lowering healthcare costs for everyone is a good first step.

No matter how this situation plays out, one thing is certain: cost containment would be an even bigger priority for health plans in a Medicare for All model. Proactive measures, such as adopting comprehensive payment integrity technology like Pareo®, can prepare you to cover all possible scenarios and better equip you for success. 

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

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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Choosing a Payment Integrity Solution: the Ultimate Guide for Health Plans

Choosing a Payment Integrity Solution: the Ultimate Guide for Health Plans

Payment integrity solutions make many claims. Here are the top 11 areas of evaluation to ensure a perfect fit for your health plan.

The healthcare data deluge is coming. Is your health plan prepared to deal with it? Most of the health plans and payers we talk with are in one of two camps: a few self-developed solutions for claims audit and recovery, or scores of piecemeal applications used by the assorted departments dedicated to different areas of cost containment.

No matter your current approach, health plans have an increasing number of advanced technology choices in front of them – all promising “the answer.” As this article puts it: “New startups emerge every day, promising to hold the panacea for interoperability, data and analytics woes. As more players enter the game, it’s increasingly difficult to weed the snake oil peddlers from those who’ve got the right stuff.”

What’s at stake? Your rate of recovery.

Choosing the right payment integrity solution for your health plan holds arguably the greatest potential impact on your bottom line. When ClarisHealth conducted a survey examining payment integrity returns on claim spend at the leading national and regional health plans, we discovered a key difference. Those payers who had in place a scalable technology solution were tripling the rate of recovery over those who were struggling with outdated applications that require a great deal of manual intervention.

Virtually every health plan is looking to move their medical savings from a typical 1-2% today to something above 5% over the next few years. As your health plan looks at the emerging payment integrity solutions on the market, two questions will guide you in your search:

  • What are the most important elements to consider?
  • How do the different options – payment integrity solutions, self-developed technology, claims editors, FWA solutions, third-party services providers – stack up against each other?

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

Get the Checklist

Click to download our Payment Integrity comparison tool.

Functionality is the Top Consideration

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

1. Supplier Optimization

The ideal payment integrity solution should optimize the value you receive from third-party suppliers. Pareo® is the only commercially available solution that optimizes third-party vendor performance to help you realize, on average, a 30% increase in supplier efficiency. Functions like overlap control, contract management and performance reporting are all integrated through a single platform. Another benefit? Onboarding a new payment integrity supplier is quick and easy.

2. Audit Workflow and Analytics

Do you have the advanced analytics necessary to boost your own overpayment recovery efforts? Access the insights needed to create internalization strategies around cost optimization in both pre- and post-pay environments with confidence, and eliminate the routine administrative tasks that bog down your valued cost containment workforce. Fully customizable, streamlined workflows integrate vendor and internal recovery management efforts and boost internal analyst activity 3x. Pareo® provides the robust productivity and quality tracking you need to run and manage a large-scale internal audit workforce.

3. Clinical Workflow and Analytics

Who has the medical record? Concerns about increasing provider friction keep health plans from taking full advantage of the skilled clinical coders and nurse auditors on staff. What if you could coordinate seamlessly between your vendors and internal resources on provider outreach to prevent overlap while internalizing the best analytics from all sources and fully reconciling each audit?With Pareo®, clients average a 7% rate of recovery, relative to claim spend. Health plans can expand clinical and audit operations with advanced payment integrity technology, while decreasing medical expenditures by 2-4% and reducing the chance of errors.

4. FWA Case Management and Analytics

Fragmented case and allegation management tools that silo data unnecessarily stifle the effectiveness of SIU teams. Without real-time system visibility, health plans and managed care organizations can only hope to control FWA – not eliminate it. Broader access to this data could have tremendous value across the entirety of your health plan’s cost containment initiatives. Pareo® breaks down these data silos to create a comprehensive solution across all audit and investigation divisions of a plan while maximizing efficiencies with case tracking, investigations, and federal and state reporting.

5. Reporting and Business Intelligence

Drive your health plan to maximum effectiveness with actionable business intelligence. Pareo® provides access to real-time metrics that can be leveraged for accurate reporting when you need it most. Our system offers role-based dashboards, allowing health plans to scale business intelligence solutions system-wide.

6. Provider Engagement

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

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

Additional Payment Integrity Evaluation Areas

A search for payment integrity technology doesn’t stop at functionality questions, particularly as a health plan evaluates various solutions and/or a more comprehensive platform. Some of the solutions that a health plan may evaluate as part of payment integrity program include: self-developed technology, claims editors, FWA solutions, and other vendors offering integrative technology.

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

1. Flexibility

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

2. Value Perks

Is the payment integrity solution in question able to identify and fill the gaps left open by current financial processes? How is ROI improved by this added value?

3. Integration and Ease of System Implementation

What training and support does the solution provider in question offer? How often do they update their platform, and how well will it integrate with current and future suppliers and providers?  

4. Data Accessibility

How important is SaaS vs. on-premise for your organization? Healthcare as a whole is increasingly moving all electronic systems to “the cloud” to increase stakeholder engagement, improve efficiencies and reduce capital investments in quickly-obsolete hardware.

5. Working with the Vendor

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

How Does Comprehensive Payment Integrity Stack Up Against Other Solutions?

When we speak with health plans and payers, we find that there’s some confusion surrounding the elements of a robust payment integrity program. In particular, a claims editing solution or a FWA tool  are sometimes seen as a complete payment integrity management tool, even though we regularly uncover gaps and hidden revenue for plans that rely on just a claims editor.  

We’ve said it before, and we’ll say it again: these modular solutions are not the same as a comprehensive PI solution. That isn’t to say they can’t work in tandem; for instance, Pareo® was created to integrate with third-party suppliers as well as optimize multiple supplier relationships for health plans. As we build this checklist, keep in mind that the benchmark is total payment integrity functionality. However, this payment integrity solution tool can be used to evaluate other elements of a payment integrity program.

Here’s how Pareo® compares to other payment integrity solutions:

  • Self-developed Technology: Self-built payment integrity solutions incur large, ongoing costs for health plans. Pareo® can be quickly implemented and offers many immediate benefits to a health plan, versus a self-built solution that will require a longer lead time before ROI is realized. Additional considerations for those considering building an in-house solution are: functions that need to be included, cost, time, and vendor integration.
  • Claims Editors: Pareo® works in tandem with claims editing solutions by improving the scope and automating much of the workflow.
  • FWA Solutions: FWA solutions, like claims editing solutions, are limited in scope and therefore not comprehensive. They should not be a health plan’s only line of defense in preventing improper payments.  
  • Third-party specialized suppliers: A health plan considering third-party vendors doesn’t have to choose between Pareo® and their business partners’ solutions. Pareo® offers supplier optimization tools that allow for platform integration, improving a payment integrity system’s performance and workflow.

 

Why should Pareo® be on your health plan’s list of payment integrity solutions to consider? Every week, we provide a no-hassle look at what Pareo® can do.

6 Signs of Outdated Payment Integrity Processes

6 Signs of Outdated Payment Integrity Processes

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

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

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

1. Efforts are Retroactive Instead of Proactive

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

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

2. Little or No Unified Reporting

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

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

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

3. Claim Processing Departments Are Competing… With Each Other

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

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

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

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

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

5. Administrative and Medical Costs Are Soaring

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

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

6. Transparency, You Say?

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

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

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

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