“The Great Pause” Brings Unyielding Uncertainty to Medical Loss Ratios but Also Opportunity

“The Great Pause” Brings Unyielding Uncertainty to Medical Loss Ratios but Also Opportunity

Are better-than-expected medical loss ratios in 2020 setting up payers to take a severe hit on profit margins in 2021? Go on offense by making moves that feature these 4 risk-mitigating hallmarks.

Six months into the novel coronavirus pandemic in the U.S., the crisis has affected the healthcare industry unevenly. While providers have been hit hard financially, health plans have experienced record profits due to a significant drop in medical expenses. But while they come under scrutiny for the current medical loss ratios, health plans argue this is a situation that cannot last. They expect a pent-up demand for healthcare coming in 2021 that will more than make up for this year’s health plan profit margins.  

None of us can predict the future. But we can still find a path forward for payers. One that helps you successfully navigate the short-term uncertainty around healthcare claims costs and poises you for long-term success. The “great pause” – as the initial lockdown period of 2020 is sometimes referred to – has changed our economy and the way health plans think about business operations for the long term.  

Will COVID-19 Delay the Payer Financial Impact? 

The Affordable Care Act mandated health plans spend at a minimum 80-85% of premiums on healthcare or quality improvements. The result is a medical loss ratio (MLR) calculated as follows: 

MLR = Healthcare Claims + Quality Improvement Expenses / Premiums – Taxes, Licensing & Regulatory Fees  

With the onset of the COVID-19 pandemic, as consumers avoided or deferred care, the “healthcare claims” portion of that equation shifted dramatically. This downward trend was most significant in the second quarter. A recent study found that in April 2020, total hospital admissions declined 34%, including COVID admissions. At the same time, visits to ambulatory practices declined 60%, and emergency room visits dropped off 42%.  

This lower-than-expected use of healthcare services has reduced medical expenses billions of dollars across commercial health plans leading to, in some cases, doubling of profits. But, what does the future bring?  

The “bad” 

Especially at the onset of the pandemic, several experts predicted catastrophic healthcare costs would accompany COVID-19 and severely hit payers’ bottom lines. That worst-case scenario hasn’t materialized, though some worry that higher costs are on the horizon as a result of early care delays. 

 Of particular concern are decreased rates of screenings, vaccinations and other preventive care. At least 40% of individuals surveyed reported delaying care due to COVID-19 through the end of June. This article cites studies that note a 46% decline in cancer diagnoses and an 85% drop in common cancer screenings. CMS data revealed 22% fewer vaccinations administered, 44% fewer screenings for physical and cognitive development, and 69% fewer dental procedures among children between March and May of 2020.   

 A predicted future spike in elective procedures is also worrisome. By some estimates, they make up 37% of health plans’ hospital admissions spending. Some of those 40% mentioned above who delayed care undoubtedly fall into this category. As of July, though, procedures had rebounded to 16% below baseline levels. And a September survey found 60% of patients are open to rescheduling their elective procedures this year, a figure that jumps to 71% among those whose needs are more urgent. 

 The “good” 

When COVID-19 forced consumers and providers to re-think healthcare encounters, it yielded a few moves that may lower costs in the short-term and the long-term: 

 Embrace of telehealth and virtual care: The adoption of remote patient monitoring, virtual visits and more has jumped forward and may help better manage chronic conditions, including behavioral health. By improving access to care, it might also help redirect the non-emergent visits that have historically ended up in the emergency department. As a PwC report noted, “Even if telehealth increases utilization, many payers see the platform as an opportunity to get members the right care at the right time in the right place while also saving the member and the employer money.” 

Creative healthcare solutions: From at-home dialysis and other home health treatments to reassessing the usual cancer treatment protocols, the hyper-focus on effectiveness has started to chip away at the “more equals better” healthcare idea.  

Alternative payment models: Those providers participating in contracts that prioritize value fared better financially than their fee-for-service counterparts – and achieve improved outcomes for their patients. Combined with modern payer initiatives that focus on social determinants of health, coordinated care, population health and the transparent data sharing that supports these moves, the current environment might signal a sea change in this shift. 

The “wait and see” 

Because we are still very much in the middle of this healthcare crisis, these outcomes – the “bad” and the “good” – are far from a foregone conclusion. In fact, the latest estimates – from the Willis Towers Watson actuarial analysis of employer healthcare cost – project 2020 totals to come in 3.3 – 9.9% lower and 0.5 – 5% higher in 2021 for a combined cost reduction of 2.8 – 3.8% from non-pandemic levels. Even still, the analysts warn about volatility around these costs. 

With this uncertainty comes risk for health plans. Uncertainty around when and where elective procedures will resume, the total COVID-19 testing and treatment costs, and how ongoing unemployment will affect insurance coverage rates all make it difficult to act with conviction. In response to this lack of assuredness in the market, some health plans have gambled on suspending long-planned strategic projects.   

However, while the novel coronavirus is our collective reality for the time being, it will pass eventually. With that in mind, does it make sense to make relatively short-term moves that may prove costly in the long run? 

4 Hallmarks of Win-Win Strategic Moves for Payers to Implement Now 

We might feel the impact of COVID-19 on healthcare through 2022. And especially in the face of potential healthcare cost volatility in 2021, health plans have to extend their long-term visioning. What strategic moves both mitigate risk now and move the needle on your competitive advantage in the future?  

Consider decisions that make sense, no matter what the future brings regarding medical loss ratios. Look for these four characteristics of moves that promise to propel your health plan past the risk-averse reactive mode that can result in inaction and unwanted setbacks. 

1. Easy to implement

When you think of plans that are easy to implement, policies and processes that are already in place may come to mind. For instance, when CMS provided payers flexibility on medical loss ratio reporting and rebates this year, health plans didn’t hesitate to exercise their options. Many had already taken it on themselves to provide direct support to consumers. This relief came in the form of waiving COVID-19 cost sharing, extending premium payment grace periods, and offering premium rebates and discounts.  

By the same turn, if your health plan is already in the process of pursuing an enterprise technology platform, consider how quickly you could realize savings from that decision. And how difficult it would be to get back on track if you abandoned that process. Emphasize your potential speed-to-value when you encounter these roadblocks, and it won’t steer you wrong.

2. Build empathy with stakeholders

As COVID-19 ravages your consumers, network providers and employer clients, any strategic move that shores up these relationships holds promise for long-term benefit. For example, extending telehealth benefits and continuing member engagement campaigns for consumer satisfaction. Evolving provider engagement programs to further ease their claims burden. And offering creative solutions to keep employer healthcare costs down. 

Some of these strategies build on the positive outcomes realized thus far into the pandemic, which also make them easy to implement. And they include policies that mitigate healthcare delays and may even lower healthcare costs, making them a good match for today’s challenges and tomorrow’s opportunities. 

3. Improve efficiency

No matter how healthcare costs impact medical loss ratios next year and the next, it pales in comparison to one perennial challenge. Administrative complexity makes up at least 10% of annual healthcare spending in the U.S. Reducing your administrative burden holds the greatest potential to increasing your profit margins.  

For that reason, prioritize decisions that will yield the greatest return on investment. Times like these increase the stakes greatly. And you simply can’t afford not to invest in solutions that could double or triple your recoveries while improving efficiency.

4. Reduce team frustrations

What issues did the pandemic bring to the forefront for your team’s day-to-day? For most of us, work flexibility and communication have become more important than ever. Work cultures that depend largely on face-to-face interactions have had to adapt quickly to maintain productivity. And your email inboxes may have taken a hit as their limitations as workflow tools have been tested. 

As a result, teams across all industries have quickly adopted virtual meeting solutions that may already have been in place. You may also consider secure, cloud-based collaborative technology platforms. Especially ones developed specifically for the healthcare industry can help you extend a work-from-anywhere posture and invite key external stakeholders into the workflow.  

Set Yourself Up for Success – No Matter What Medical Loss Ratios Bring 

While there continues to be talk about “getting back to normal,” we may have to recognize that the new normal equals uncertainty. We have to become agile enough to succeed under those circumstances. Take this opportunity to implement solutions that address inefficient processes. Innovate your way through broken relationships with stakeholders. A scalable technology platform like Pareo can help you transform your payment integrity function, which better positions you to successfully navigate unpredictable medical loss ratios and their impact on profit margins. 



Talk to ClarisHealth about how Pareo®, a total payment integrity platform, is driving innovation at health plans. 

Health Plans Launch Innovative Solutions to Respond to Mental Health Crisis

Health Plans Launch Innovative Solutions to Respond to Mental Health Crisis

Transparent data sharing supports seamless care coordination, relevant outreach that mitigates effects of chronic conditions. 

The novel coronavirus pandemic continues its near-perfect record as a harsh but effective teacher for the healthcare industry as it efficiently evolves systemic weaknesses into full-blown crises. Patient and procedure volume-based reimbursement structures? Check. Primary care access? Check. Healthcare coverage? Check. Now we can add the mental health status of Americans to that list. But, even with these issues, the ability to steer through the challenges and find our way to an appropriate solution is still within reach. And payers, with their increasing focus on whole-person care, are particularly suited to drive these changes.  

How can health plans promote improved access and outcomes in mental health while controlling costs associated with this expensive chronic condition during the pandemic and beyond? And what are the implications to health plan payment integrity operations? Let’s explore the landscape and potential solutions. 

Challenges: Access and Expense 

It’s estimated that 1 in 5 Americans suffer from mental health issues. It’s a problem that’s already been increasing in severity across our population, especially among teens and young adults. But with the onset of the pandemic, there are signs that figure may be increasing dramatically. 

Increased isolation, grief, job losses, pressures from juggling home/work/childcare responsibilities, extended uncertainty and more are creating and worsening anxiety and depressive disorders. And, among frontline healthcare workers and other essential employees, in particular, there are concerns with potential long-term PTSD-akin effects. Experts predict an associated increase in suicides, overdose deaths and substance use disorders as well. 

Why are these rising cases such a concern? There are two big perennial challenges associated with mental healthcare.  

Limited access to care

Without proper intervention and maintenance, there is risk of situational mental health issues becoming chronic and existing mental health conditions becoming increasingly severe. But while 20% of Americans experience mental illness, historically less than half receive treatment. This limited access to appropriate care has a variety of causes. While there are cultural barriers – concern about perceived stigma, for instance – structural barriers are just as restrictive.  

At least 60% of U.S. counties don’t have a single practicing psychiatrist, so even for those patients covered by insurance, access is an issue. They struggle to find in-network mental health providers that will take their insurance. One study found that these patients with commercial insurance were up to 15% more likely to receive out-of-network care than other chronic disease patients, and their cost burden was almost 4 times higher. 

And, for those who have managed to get treatment, the pandemic has limited their in-person visits and put their providers in a precarious financial position. Already vastly underfunded, fragmented and difficult to access, mental health providers have been just as impacted financially as other healthcare providers. But because relief funding is largely based on Medicare rates, rather than Medicaid, community behavioral health centers were less likely to pursue and receive support.  

Mental health and addiction providers estimate they will lose $38.5 billion in revenue in 2020, and more than 60% of providers had already been forced to close at least one program before the end of April. Close to half of mental health and addiction providers report their chances of survival at 6 months or less in the current fiscal climate, minimizing their ability to act as a safety net when they are needed most.   

Expensive to manage

Mental health conditions negatively impact quality of life and economic productivity, which are grave enough consequences. But in addition to the healthcare industry lacking sufficient mental health resources, it is also one of the more expensive chronic conditions to manage. In 2019, the U.S. spent over $225 billion on mental health services, or 5.5% of total healthcare spending, and that dollar amount has increased over 50% in the last 10 years.  

Direct spending on mental health services doesn’t paint the full picture. Mental illness is disproportionately associated with physical chronic conditions as well – cardiac, pulmonary and obesity comorbidities. In fact, depression quadruples the risk of a heart attack. And taken together, these issues create a much bigger impact. According to the CDC, 90% of national healthcare spending goes towards managing chronic conditions and mental health.   

Approximately 75% of those with severe mental illness (SMI) have at least one chronic physical ailment, and the number increases among vulnerable populations. One study of Medicare beneficiaries found 12.7% of spending was associated with mental health disorders, but mental health services only made up 4.2%. In fact, patients with an SMI reflected a 37% increase in physical healthcare costs, and an 18.4% increase for those with other common mental health disorders.  

Opportunities: Telehealth and Whole-Person Care  

Even with these systemic challenges associated with mental healthcare, promising signs have emerged that hold the potential to mitigate their effects, including rapid adoption of telehealth and payers increasingly focused on whole-person care.  

Accelerated virtual care adoption 

Telehealth use already found its niche in behavioral healthcare, especially in underserved areas. But with the stay-at-home orders, telehealth claim lines increased more than 8,335% from April 2019 to April 2020. Mental healthcare was a big driver of those visits, but chronic condition management made big gains in virtual care adoption as well.  

Teletherapy offers distinct advantages for mental health patients, not the least of which is extending access to mental health providers when availability or convenience is an issue. It also eliminates the need for travelling to an appointment, allows for a familiar environment and may even mitigate concerns of stigma. Mental health providers, too, see benefits by gaining insights into the home environment and allowing patients to more easily maintain valuable therapeutic visits. 

Even though many patients had little to no experience with telemedicine or other forms of virtual care, most have been pleased with the encounters and want to see it continue indefinitely. And, in the same way payers have seen success with virtual care for monitoring and managing physical chronic conditions – and creating patient trust in the process – there is reason to expect similar results with mental health conditions. 

Increasing focus on whole-person care  

Health plan models are increasingly centered around improving the delivery of person-centered care. How can you treat the whole person and engage provider, patient and other stakeholders after the encounter? Two different models of coordinated care for better integrating mental health are common.  

Co-location of services – where mental health and primary care providers physically exist in the same place – offer economies of scale, efficiency and improved outcomes that benefit health plans. Looser collaboration agreements don’t require a provider organization to deliver the full array of services, provided they work closely with others across the service delivery ecosystem to ensure coordinated access to care, but does necessitate a technology infrastructure that supports true data interoperability. 

For health plans, both models see the full array of services – for mental health and physical healthcare – covered under a single agreement with a goal of positively impacting utilization and health outcomes. And new clarity on privacy regulations makes it more straightforward for providers to coordinate care for those patients suffering through a crisis. 

Innovative approaches to coordinated care promise to unlock value for payers, providers and consumers by supporting alternative reimbursement models; offering leeway on care modalities to include telehealth, remote patient monitoring technologies, and care management home visits; and providing real-time care integration. Many health plans are relying on integrative technology solutions as a backbone to power a seamless patient care experience, and these benefits extend to behavioral health.  

Advanced Technology Enables Relevant and Sustainable Solutions 

While the challenges – and opportunities – are significant, health plans don’t have to pioneer entirely new programs in order to improve systems for mental healthcare maintenance and intervention. Engaging members and providers via current advanced technology initiatives can strategically extend this function. 

Member engagement 

A new poll confirmed what we already feel to be true as consumers: the healthcare industry is simply too complex to navigate effectively. Respondents overwhelmingly cited every aspect of healthcare – care access, management, and payment – as needing to be streamlined and simplified. “They want health plans and providers to end the fragmentation, simplify the experience, and deliver a fully connected encounter that makes healthcare as seamless as any other online endeavor.”  

Arguably, the system proves to be even more unnecessarily opaque for those experiencing mental health issues and their support system. And those with mental health disorders are at higher risk during the pandemic. Many health plans already prioritize seamless member engagement opportunities, supported by modern communication modalities. But, as we wrote in a previous article, consumers want to hear from their health plans more, especially with relevant information. One payer program of this type is already seeing the benefits. 

Additionally, more advanced solutions like population health management platforms, such as that offered through Pareo, allow you to proactively assess disease risk among your membership. Taking this opportunity to reach out to members about their telehealth options, the importance of medication adherence, information about prescription assistance, wellness options, chronic disease management, checking in with a primary care provider, how to better protect themselves from COVID-19 and more promises to yield significant dividends.  

Provider engagement 

Many behavioral health providers and facilities still receive most of their revenue from fee-for-service reimbursement, but from there member experience can unravel. Some payers will not give reimbursement checks to a facility directly, but rather to the plan member. This can create abrasion between the patient and provider as well as the provider and the payer, but that risk can be mitigated through strategies like prospective cost avoidance and coordination of benefits.  

However, in order for mental health providers to shift revenue management strategies, health plans need to be in a place where they can support prepay. Pareo is a seamless payment integrity solution that can power retrospective and prospective claims recovery. It does this in part through automated workflows and by housing relevant medical claims data, enabling plans to hold up their end of prospective cost avoidance.  

Related to mutually beneficial payment structures, a survey conducted in March 2020 indicated 74% of primary care organizations and 61% of behavioral health organizations participate in some form of value-based reimbursement. But, only 16% of those organizations have 20% or more of their revenue in such an agreement. With health plans looking to accelerate adoption of alternate payment models, it’s important to keep in mind what’s essential to their acceptance and ultimate success. 

Extending clinical data interoperability, integrated workflows, proactively identifying gaps in care, and real-time metrics are key components of modern value-based contracts. When health plans better engage with mental health providers, those providers are empowered to better support members. And transparent data sharing – like that supported by the integrative platform Pareo – extends health plans’ abilities to do exactly that.  

Pareo Provider is a seamless technology platform for real-time engagement with providers, including specialty providers. Not only for the purposes of payment integrity – though Pareo effortlessly accommodates complex reimbursement contracts and supports two-way communication on claims. But also new information on virtual care allowances, sharing quality metrics, getting credit for SDOH assessments and more – without increasing the provider or payer administrative burden.  

Pareo is a Single-source Solution for Payment Integrity Operations

Understanding trends in behavioral health management is vital to health plans, and payment integrity teams must take note of the implication of mental healthcare utilization on their operations. With only half of those who suffer from mental health conditions receiving care, and many members eligible for care struggling to find access to providers, complexities abound. Further, many mental health providers and facilities are using outdated payment models, because before the Affordable Care Act, mental health was often not a covered health insurance benefit.  

Pareo is a single-source payment integrity solution that can integrate with myriad data systems to power even the most nuanced retrospective and prospective claims recovery efforts. Within Pareo, features that support provider engagement, population health management and prepay can facilitate (and automate) facets of behavioral health claims management to create a better experience for payers, providers and most importantly – patients. 


Talk to ClarisHealth about how Pareo®, a total payment integrity platform, is driving innovation at health plans. 

Healthcare Interoperability Poised to Solve COVID-19’s Big Data Crisis

Healthcare Interoperability Poised to Solve COVID-19’s Big Data Crisis

Coronavirus highlights power of big data and the need for interoperability to improve population health. How can health plans lead the way? 

What’s the single biggest weapon used by government, pharma, academic researchers, healthcare systems, and health insurers alike to combat the novel coronavirus pandemic? It’s data. Massive amounts of data. Unfortunately, we’ve said it before, and it bears repeating: healthcare has a data problem. And, like many things in healthcare, the current crisis has brought this deficiency into focus. 

In this article we’re exploring the many uses of big data for the coronavirus and beyond and how health plans can overcome the obstacles to ingesting and processing data from a myriad of sources to achieve interoperability, positively impact population health and secure their competitive advantage. 

Big Data and the Coronavirus: A Unique Use Case

Already, work involving advanced analytics applied to real-world data is seeing success in combating COVID-19. By analyzing publicly available datasets, scientific literature, social media information and their own data, progress of a sort has been made by different groups: from predicting adverse events in coronavirus patients to rapidly developing potential vaccines. But the propensity for healthcare, academics and industry to stick to their silos – and their information right along with them – has limited their potential for reliable successes. 

Challenges to leveraging healthcare data

Despite generating a ton of healthcare data – most of it now digital – much of that data is still incomplete, irrelevant, inaccessible or a combination of these. And the sheer volume makes it difficult to overcome these deficiencies. By some estimates, we’re generating over 2,300 exabytes per year (one exabyte = one billion gigabytes), which is expected to grow at least 36% year over year through 2025. 

While compute power has evolved to handle the sheer amount of information, this data is locked in silos. In the absence of clinical trial data – the gold standard – real-world clinical information from COVID-19 patients is the most useful in guiding medical decisions. Thanks to a decades-long push to digitize healthcare information, this data exists inside electronic health records. Despite the promise of digitization, EHRs have not made it easy to retrieve this crucial data.  

Built as they were with billing efficiency in mind, most of the useful clinical data is stored as unstructured free text. And without a common architecture, labels are inconsistent, which makes sharing difficult – even in rare cases where data is complete. There are reports of providers unable to deliver detailed clinical data on coronavirus cases, largely because it would have to be printed or tediously copied from EHRs, then sent by fax or email, or manually entered into CDC forms. 

Interoperability and collaboration offer keys to success


The new rules against information blocking have been delayed to free up resources devoted to the pandemic response, but the need for data interoperability has never been greater. When health data is shared, front-line providers are informed in real time on patient movement, health changes and diagnoses, allowing them to respond smartly. 

According to the Office of the National Coordinator for Health IT’s Don Rucker, M.D., the current COVID-19 pandemic is a clear example of why the data sharing regulations are so critical. “Ironically, if we had this rule several years ago, we would be in a far better spot for knowing what’s going on with this pandemic. There are fundamental things about the biology of this virus that we don’t know, such as latency, duration of disease and how immunity is built up. It would be easier if we had richer clinical information streams.” 

One success story demonstrates just how essential data interoperability is to identifying vulnerable populations and performing targeted outreach. The regional data network had already taken the steps to integrate health information from numerous providers in the area, so they were well positioned to respond quickly during the COVID-19 pandemic. But they were still limited to barely more than a third of the county’s population in this initiative, which shows there’s still plenty of work to be done. 

Other successes tell a similar story. Working together, sharing information – even among competitors and others that don’t traditionally collaborate – accelerates the path toward viable coronavirus solutions. Making quality data more readily available should be the goal. As one expert in public health research puts it, “How can we continue to work together and invest in these infrastructures so that we can collect data, share that data, and analyze that data rapidly in pandemic situations? Or even in smaller-scale situations, like a localized outbreak of food poisoning or salmonella?” 

Where is all this data coming from?

In 1950, the doubling time of healthcare data was 50 years; in 1980, 7 years; and in 2010, 3.5 years. Today, that rate is 0.2 years—just 73 days. These increasingly varied sources of digital data all offer value, though few health plans are able to ingest and parse all of them. 

  • EHR 
  • Claims systems 
  • CRM 
  • Rx data 
  • PACs 
  • Lab data 
  • Clinical Trial Management systems 
  • ACOs/HIEs 
  • Genomics and research registries 
  • Wearables 
  • Apps 
  • IoT 
  • Chatbots 
  • Medical devices and sensors 
  • Social media 
  • Machine logs 
  • PHR systems 

How Health Plans Can Push Data Interoperability Forward 

Now that the pandemic has reinforced the need for improved sharing of healthcare information, what comes next? Like the push for EHRs to streamline healthcare billing, it’s likely health plans will again have to lead the charge in the journey to healthcare data interoperability. We outlined before 4 steps health plans can take to comply with the new information blocking rules. In addition to technical compliance, there are 3 things health plans can do to promote interoperability more broadly in the industry. 

1. Adopt modern technology with interoperability in mind 

The assortment of fragmented technology and manual systems currently in use at many health plans will no longer cut it. Every internal operations system – the claims adjudication system, CRM, fraud detection, payment integrity, provider outreach tools, member service chatbots and everything in between – must be able to “talk” to each other. Moreover, two-way interaction between external provider systems like EHRs and members’ apps of choice also will be required. Advanced integrative technology platforms like Pareo leverage modern APIs built on the FHIR standard to support interoperability. 

2. Use A.I. to process data 

Once health plans have ingested data from myriad sources, processing that information into real-time insights is the next logical step. But even with data interoperability standards in place, healthcare information is still likely to be largely inconsistent and unstructured. Applications of A.I. like supervised and unsupervised machine learning, natural language processing and more can help overcome these challenges, turning raw data into visualized business insights. 

3. Share insights 

Once a health plan has done the dirty work of ingesting and analyzing healthcare data, that’s where the real value of promoting interoperability comes in. Sharing insights with relevant stakeholders – providers, members, even other health plans – builds trust and the ability to realize the benefits of big data across the healthcare continuum. 

Benefits of Big Data Interoperability 

While healthcare data interoperability promises many benefits during a pandemic, innovations pursued now promise to pay dividends long into the future. We’ve written about a few of these during our recent series of articles covering long- and short-term effects of COVID-19. 

For one, without data interoperability, the transition to value-based care is a non-starter. Sharing mutually beneficial information with providers is the foundation of fostering these valuable relationships. It’s up to health plans to take the reins on opening the lines of communication with providers, and supporting them with relevant clinical information can help them reduce costs while improving care. 

The coronavirus pandemic has unfortunately affected members as well, particularly their healthcare coverage and finances. As a result, they have been more likely to delay needed care – even for chronic conditions that make them more vulnerable. At the same time, they are signaling they are more open than ever before to receiving communications from their health plan. This convergence provides an ideal opportunity for health plans to leverage big data insights for population health management efforts. Advanced technology like Pareo surfaces lists of those members most likely to need engagement and care to improve healthcare access, outcomes and quality. 

Finally, greater information sharing allows health plans to make more informed decisions faster. Where are the errors, areas of high-risk and opportunities for driving changes? Access to the “big picture” ensures strategic planning that secures a health plan’s competitive advantage. 

Health Plans Find Success with Tech-Forward Strategies 

COVID-19 has thus far proved to be a harsh but effective teacher, not least by emphasizing the need for an interoperability record that helps to provide comprehensive clinical insights with a 360-degree view of members and patients. This initiative is only feasible through advanced technology. Those health plans with digital-first strategies already in place are better set up for success, but payers that lag can still make progress and secure their competitive advantage. 

By adopting scalable comprehensive technology and leveraging modern interoperability standards, health plans can position themselves to excel at payment integrity, coordinated communication and population health efforts alike. As the COVID-19 crisis evolves – and in readiness for when the next healthcare crisis presents itself – payers will be able to lead the way in identifying those at risk based on their clinical predisposition, genetics, social determinants of health, and other factors as well as coordinating member and provider engagement. 


Talk to ClarisHealth about how Pareo®, a total payment integrity platform, is driving innovation at health plans. 

From Volume to Value: Alternative Payment Models Win During a Healthcare Crisis

From Volume to Value: Alternative Payment Models Win During a Healthcare Crisis

As patient volumes drop due to the COVID-19 pandemic, fee-for-service payment models hurt providers. Is this finally the time for value-based care? 

COVID-19 is decimating provider finances. Hospitals are losing over $40 billion per month in lost revenue due to canceled non-emergent inpatient and outpatient procedures. Physician practice revenue has been cut in half. These financial impacts are the direct result of the volume-based contracts in place at many providers, leading some to ask if this might finally be the right time for value-based care. In the words of one payer executive, “If there’s a silver lining to the crisis, it’s that we will now explore a value-based model which is going to be good for patients, good for providers and good for the community.” 

Let’s examine how fee-for-service reimbursement became the norm in healthcare, how it compares to value- and risk-based agreements, and how health plans are better positioned than ever before to successfully promote and implement alternative payment models like value-based care. 

A Brief History of Healthcare Payments 

Our last article in this series on the far-reaching impacts of the novel coronavirus pandemic called out that the structure of our healthcare industry has been in place for almost a hundred years. For the first half of the 20th century, fee-for-service payments made sense as there were limited numbers of interventions and medications that could be offered, and those were relatively low-cost.  

Medical advancements raise complexity, cost  

As medical advancements were made, complexity and cost increased. When the Medicare and Medicaid programs were created to help the elderly and low-income population receive care despite higher costs, their method of reimbursing for services provided the foundation for fee-for-service reimbursement. Later, as costs continued to increase, payment reform concentrated on payment caps but kept FFS reimbursement intact, which led to providers increasing the number of reimbursable services and patient throughput to maintain revenue.  

The rise of managed care and value-based care 

In the 1990s, “managed care” initiatives slowed the growth of healthcare spending by reducing utilization. But they also concentrated healthcare decision making outside of the patient-provider relationship, which unnecessarily increased friction and led to their demise. In 2010 the Affordable Care Act mandated a few value-based care programs administered by CMS. Bundled payments that offered higher fees for higher-quality providers were also introduced as a middle ground between FFS and capitation. 

Though there have been gains in value-based care contracts, most provider revenues are still based on patient volume. A recent survey revealed that while 57% of provider respondents were participating in value-based care arrangements, 48% report that over three-quarters of their organization’s revenue is tied to FFS. 

It’s not just finances, it’s personal: Provider burnout exacerbated by COVID-19 

The financial hit that providers are taking is secondary to the fact that many are putting their lives on the line as they stand at the forefront of the novel coronavirus crisis. But health plans are paying attention to an underlying issue many providers face: professional burnout. 42% of physicians surveyed in 2018 reported feeling burned out while 15% admitted experiencing some form of depression. Those most likely to be burned out are the same ones most likely to be working the front line: critical care, internal medicine and emergency medicine.  

It’s possible that a shift to value-based care and telehealth could offer more work-life balance for medical professionals, and health plans are taking note as they look to support their networks of providers during and after this healthcare crisis.  

Why Continue Fee-for-Service 

Especially in the short-term, fee-for-service reimbursement provides a straightforward, familiar model that encourages providers to continue to offer healthcare during a time when its most needed. And, as many states lift restrictions on elective procedures, many providers expect pent-up demand for healthcare to rebound patient volume and revenue right along with it. Close to 40% of people who had elective procedures canceled plan to reschedule. 

ACO experiences 

Accountable Care Organizations make up a big chunk of the providers participating in alternative payment models. But with their large Medicare populations, the coronavirus pandemic created more risk than they had planned on. In a survey, more than half of ACOs, which earn shared savings based on total spending, were considering exiting the program due to uncertainty and expected financial losses. 

Fortunately for ACOs, CMS stepped in with a new rule that aims to protect them from unforeseen financial impacts. These changes remove spending on COVID-19 patients from performance calculations, expand the definition of primary care services to include telehealth, and more. Nevertheless, this scare may deter other providers from participating in value-based care arrangements. 

Risk-averse providers

Historically, providers have been reluctant to take on the additional risk inherent in value-based care contracts. And, who can blame them? It has been difficult to come to consensus on what “value” and “quality” really mean, and lack of data interoperability only exacerbates that issue by keeping essential information on outcomes out of reach for providers. Furthermore, even before the COVID-19 crisis, many providers were already struggling due to burnout, financial issues and hospital closures. 

When providers enter into alternative payment models, it takes significant resources. With increasing Medicaid and uninsured populations, they may not have it to spare. Physician practices are closing and increasing consolidations are expected in the wake of the novel coronavirus pandemic. This translates into reduced capacity for preventive care and less provider incentives to engage in risk-sharing.   

6 Primary Payment Models

While fee-for-service will likely always exist in some form, in response to growing healthcare costs (now almost 20% of GDP), public and private payers have launched innovative provider payment models designed to reward value over volume. Source 

  • Fee-for-service 
  • Bundled payment 
  • Capitation 
  • Pay-for-performance / Shared savings 
  • Blended payment 
  • Salary 

Why Transition to Value-Based Care  

While an immediate switch to at-risk contracts may not be advisable, long-term, value-based care promises to position the U.S. healthcare system to better respond to future healthcare crises. Those providers currently participating in alternative payment models haven’t experienced the same drop in revenues as those whose survival depends on patient volume. And they are more likely to pursue population health improvements that stand to keep their patients healthier during the pandemic. 

Surprise assist from telehealth 

One unexpected boon from the pandemic is the increased adoption of telehealth. Investments in telehealth and other methods of virtual care are key moves by providers that lend themselves nicely to value-based care initiatives of lowering the cost of care and increasing patient engagement. These investments were made because payment parity kicked in. Before, according to one survey, 60% of primary care clinicians reported the majority of their work was not reimbursed or funded, a big portion of which was telehealth.  

Now, telehealth allows them to accommodate surges in capacity, if needed, and focus on caring for vulnerable populations, so important during a pandemic that disproportionately affects these groups. As one physician says about the pandemic recovery and the role of virtual care in population health management, “This is going to be a phased-in thing and the sickest of the patients are the ones that we need to continue to be able to see to provide care for and get reimbursed for in a virtual modality.” 

Change slow but inevitable 

Those providers who continue to cling to FFS may be left behind and unable to participate in many future healthcare initiatives. CMS, in particular, has been transitioning to value-based care at an accelerated rate since the ACA was passed 10 years ago. A 2019 report showed that 35.8% of total U.S. healthcare payments in 2018 were tied to alternative payment models, a year-over-year increase of 34%. 

Moreover, the industry has begun to come together on value measurements and alternative payment model frameworks. Government payers and commercial health plans are still the primary drivers of value-based care, but universal standards go a long way towards removing uncertainty by increasing transparency. 

How Health Plans Can Support Alternative Payment Models 

We’ve written before about how payers can best support the transition to value-based care: improve provider relationships and data transparency with the help of advanced technology. That advice hasn’t changed, though the COVID-19 crisis may have increased the importance of these initiatives. 

Provider communication 

Collaboration and shared understanding enabled by real-time, two-way communication with providers is essential to the success of value-based care programs, and there is still plenty of work to do in this arena. A recent survey showed that as many as 18% of providers have zero trust in the payers they work with, and more than a third have no communication with those payers. We wrote in a previous article that the COVID-19 crisis has led payers to increase their support of providers, which may provide an opening for health plans to shore up these relationships.   

Without trust, it’s difficult to ask providers to assume more risk. In fact, a survey found that primary care physicians who trust the health plans they work with are more than twice as willing to engage in risk-sharing. As a stakeholder at a regional commercial health plan puts it, “Value-based care is payer driven, but provider and hospital partners need to come together and recognize something bigger. We’re not just trying to do something niche. We’re trying to help people prosper across our population.” 

Data transparency 

Value-based care initiatives depend on data as well. Data that reveals which populations need targeted outreach and how healthcare impacts outcomes is valuable to payers and providers alike. Lack of data interoperability between payers and providers is the number one roadblock that prevents healthcare innovation.  

Breaking down data silos can help mitigate the differing interpretations of value and quality that hold back progress on alternative payment models. So, measure everything. Every impact—clinical quality, consumer experience, return on investment, and more—should be quantified, analyzed, improved, reanalyzed and continually improved in collaboration with providers. Work with providers to implement an analytics and communications platform to share data insights and work together on continuous improvements and innovations.  

Advanced technology essential 

Value-based care promises to lower the cost of healthcare and improve outcomes. These goals were important before the emergence of the novel coronavirus and are now essential directives. But these risk-sharing contracts require advanced technology in order to implement them. CMS has suspended data collection and quality reporting so providers can focus on patient care, but health plans executing on advanced digital strategies won’t miss a beat.  

With integrative technology like Pareo in place, health plans can seamlessly communicate with providers and ingest electronic clinical care and claims information without unduly burdening these valuable relationships. They can come together in identifying and engaging those members who are in most need and find efficiencies without sacrificing quality or the doctor-patient bond. It’s the future of healthcare and it’s achievable now. 


Talk to ClarisHealth about how Pareo®, a total payment integrity platform, is driving innovation at health plans. 

Coronavirus New Normal: What does it mean for health plan members?

Coronavirus New Normal: What does it mean for health plan members?

25 million Americans projected to lose employer-sponsored healthcare coverage due to the COVID-19 recession. How will this disruption affect the relationship between health plans and consumers? 

As of the end of April 2020, about 30 million people in the U.S. are newly unemployed due to the pandemic-fueled economic shutdown, a sharp uptick from the recent historically low unemployment rate. Because, on average, about half of the people in this country receive health insurance through an employer, this situation is threatening healthcare coverage during a healthcare crisis. How is this disruption affecting health plan operations and consumers, and will it create longer-term changes in how the majority of Americans receive health insurance? 

The Financial Impact 

A variety of government and social policies in the 1940s and 50s led to the current state of healthcare coverage in the U.S. where most individuals receive insurance through an employer-sponsored health plan. While that structure functions fairly well during periods of low unemployment and underemployment, it can leave a gap during a climate of economic and job uncertainty. 

In the 6-week period between mid-March and the end of April, the unemployment rate soared from sub-5% to over 16% as efforts to stem the spread of the novel coronavirus ravaged the economy and led to widespread furloughs and layoffs of workers. By some estimates, that massive job loss has resulted in 12.7 million Americans losing their healthcare coverage at the same time they can least afford to replace that coverage. 

Health plans started to see the fallout of this rapidly changing situation almost immediately. One of the largest health plans in the nation reported that the number of its premium base requesting grace periods and payment plans increased from 0.4% to over 3% by mid-April. However, this standard practice of 60- or 90-day grace periods is expected to be not nearly enough relief for many members, leading one to offer premium credits and other financial assistance. 

Recognizing the potential impact to cash-strapped consumers, assorted medical and insurance groups are lobbying for assorted financial and healthcare coverage support measures: 

  • Offer employer subsidies 
  • Subsidize or cover COBRA benefits cost 
  • Open special enrollment periods 
  • Increase subsidies for ACA marketplace plans 

Already enacted is a 6.2% increase in federal matching Medicaid funds to help states handle the pandemic for the duration of the national public health emergency. Included in the eligibility requirements for the enhanced funds are provisions that require states to not unduly prevent qualifying individuals from receiving Medicaid coverage. 

The Healthcare Impact 

Consumers losing their income and reliable health insurance coverage during a healthcare crisis is an untenable situation. recent survey revealed a potentially precarious financial situation for a segment of the population. When asked if they would seek medical attention if they presented with the signature symptoms of COVID-19, 14% said they would avoid care due to cost. Even when asked specifically to imagine a suspected coronavirus infection, 9% still would avoid treatment. These responses were especially likely for those with lower incomes, a group that has been disproportionately affected by the current economic crisis. 

This hesitation to seek care couldn’t come at a worse time as the delays promise to derail chronic condition outcomes as well as public health initiatives related to the pandemic. However, putting off care due to financial constraints isn’t an entirely new experience. An annual poll, most recently conducted in November 2019, showed that a record 33% of Americans put off needed medical care due to costs, a rate that has increased 50% over the past 20 years. 

Health plans and the government have stepped in to encourage people to continue to seek healthcare if they need it. Health plans by temporarily waiving cost sharing for coronavirus testing and treatment, as well as other services for vulnerable Medicare members, and the government by compensating providers for uninsured care at Medicare rates so providers don’t unnecessarily burden patients without a safety net. 

Health Insurance by the Numbers

The latest healthcare coverage data available is from 2018. After years of improvement in the uninsured rate, starting in 2010 with the enactment of the ACA, the rate has increased for 2 years in a row, particularly in states that haven’t expanded Medicaid. 

  • Employer Insurance 55.1% 
  • Medicaid 17.9% 
  • Medicare 17.8% 
  • Individual Market 7.5%  
  • ACA Marketplace 3.3% 
  • Military 3.6% 
  • Uninsured 8.5% 

The Future of Healthcare Coverage 

With the rising costs of healthcare coverage shouldered by employers, and the opening of the ACA marketplace, some analysts predicted that 90% of employers would have abandoned sponsored health benefits packages by now, in the same way pensions gave way to 401(k) plans. That projected reality hasn’t yet come to fruition, though the rates of “underinsured” individuals with employer plans are increasing  

The number of uninsured employed people is also increasing, according to a recent studyIn fact, 70% of the uninsured were employed but not offered an employer-sponsored health plan while 30% didn’t enroll in employer coverage because of high costs. At the same time, high rates of unemployment bring into focus the potential gaps created by tying healthcare to jobs, and we likely have not reached peak unemployment in the COVID-19 recession. 

Single Payer Unlikely for Now 

Though the past couple of years saw single-payer policies gaining traction, strong lobbying against the structure has prevailed for now. However, much depends on how quickly the economy rebounds and to what degree. Large corporations make up much of the enrollment in employer-sponsored health plans and continue to drive that segment, and many of them have weathered this economic downturn with greater resilience thus far 

Though healthcare independent of the workplace is currently more important than ever before, the current system is still working for many people. Enhancing ACA plans and subsidies and expanding Medicaid to more people are the most cost-effective – and quickest to implement – efforts and stand to benefit those most affected by income hardships. 

Higher Medicaid Enrollment 

Experts released a new report that projects unemployment will reach 20% by June 2020, which would lead to between 25 million and 43 million individuals dropping out of employer health plans. Of those, 12 million to 21 million will enroll in Medicaid, 6 million to 10 million will receive individual coverage through the ACA marketplace, and 7 million to 12 million will become uninsured. According to a senior policy advisor, “Our safety net is about to be tested, and it’s going to work a lot better in states that expanded Medicaid.” 

Data Insights Key to Health Plan Response 

Short-term, for health plans this shift means a dramatic change in their lines of businessHealth plans that cannot quickly pivot based on data and market changes are at risk. If employer-sponsored coverage changes for the long-term, are health plans positioned to navigate these twists and turns 

Some payers are already making moves specifically focused on expanding their Medicaid and Medicare portfolios. As stated in the announcement of one of these deals, the health plan’s “strengths and capabilities will be critical to successfully serving new populations if a recession increases Medicaid membership.” At the same time, health plans report uncertainty in their 2020 projections, as small group enrollment drops and Medicaid rolls increase. Health plans are having to prepare for all eventualities, and advanced integrative technology – along with the data insights it provides – can provide the edge they need. 

Evaluate Consumer Behavior Changes 

Health plans are keen to harvest business insights from member behavior during this time. They anticipate the pandemic changing the way care is delivered for at least 1-2 years and likely, forever. Most health plans are anxiously awaiting the emergence from the “first wave” of COVID-19 cases (possibly this Summer) to see how user behavior is affected and try to strategize on long-term effects. 

With so many workers furloughed or laid off, we may see a return to insurance after this first emergence, which provides a strong opportunity for health plans to find an early indicator of longerterm behavior change that would impact their bottom line. Data on utilization of care, self-insured rates, changes in plan levels and HSAs, and more will prove valuable. 

Reduce Administrative Complexity 

Administering Medicaid MCO plans is a more complex operation, especially as CMS has issued waivers to help states be more nimble in responding to coronavirus. Medicaid lines of business also tend to be less profitable than employer-sponsored insurance. Increasingly, health plans and payers are turning to advanced payment integrity technology like Pareo to streamline coordination of benefits and otherwise ensure proper payments to providers.  

And, by virtue of being an integrative platform, it helps reduce administrative lift in tangential operations related to traditional payment integrity efforts as wellPareo supports health plans in seamlessly shifting internal resources to more easily accommodate changes in LOB, and automating communication with suppliers and providers to ensure changes are relayed effectively and efficiently.  

Improve Engagement 

Leaders of health plans know that the way insurance is delivered may change for many consumers and, particularly for Medicaid enrollees, engagement is paramount. Technology enables them to proactively address at-risk populations, like those with chronic conditions who may be particularly vulnerable to disruptions in care. By delivering broader data insights and supporting communication with internal and external stakeholders, Pareo aligns with a broader strategic effort at health plans to “improve engagement in healthcare.”  


Talk to ClarisHealth about how Pareo®, a total payment integrity platform, is driving innovation at health plans. 

Coronavirus Boosts Telehealth Adoption

Coronavirus Boosts Telehealth Adoption

The COVID-19 pandemic prompts payers to encourage the shift to telehealth, a move supported by patients and providers. How will this change the future of healthcare delivery? 

The novel coronavirus stopped traditional healthcare in its tracks, but there’s one bright spot: telehealth. As technology has advanced over the last several years, it seemed as though at any moment, telehealth would finally take off. But while the market size of the telehealth services industry growth has outpaced other areas of healthcare, with 25% average annual growth from 2015 to 2020, relatively few of us have experienced a virtual healthcare visit. That is, until now. 

Recognizing the potential of telehealth to provide safe and continuous care to those in need – both potential COVID-19 patients and those in need of other non-emergent healthcare – the CARES Act stimulus package offered $200 million through the Federal Communications Commission to medical groups to help them install the technology and fund broadband installations. At the same time, CMS and commercial health plans have temporarily introduced payment parity and relaxed some regulations that have traditionally held back progress on the initiative. 

These interim changes and financial support have dramatically increased provider, patient and payer experiences with telehealth, and early surveys indicate general satisfaction and acceptance. What does this mean for the future of telehealth? Here, we explore how telehealth has evolved in recent years, including traditional barriers to adoption, and how the pandemic has accelerated the way forward. 

What is telehealth?  

The Center for Connected Health Policy defines telehealth as “a collection of means or methods for enhancing health care, public health and health education delivery and support using telecommunications technologies. Telehealth encompasses a broad variety of technologies and tactics to deliver virtual medical, health, and education services. Telehealth is not a specific service, but a collection of means to enhance care and education delivery.”  

While the term “telemedicine” is used for traditional clinical diagnosis and monitoring delivered by technology, telehealth is used more broadly to cover the wide range of diagnosis and management, education, and other related fields of health care, including dentistry, counseling, physical and occupational therapy, home health, chronic disease management and more. It also covers live video visits, mobile health data, remote monitoring via connected devices and store-and-forward technologies for secure sending of health information. 

Barriers to Telehealth Adoption  

Even before the novel coronavirus pandemic took hold, telehealth was slowly expanding, but there were numerous challenges to its widespread adoption, the biggest of which were complex regulatory barriers and lack of payment parity. 

First, regulations vary depending on CMS, state Medicaid, and state commercial health plan requirements. All are different but restrictions on type of service, location of service (both provider and patient), provider credentials, cross-state visits and/or state licensure and more are common. That said, according to a recent survey, 42 states and Washington, D.C., now have some sort of telehealth commercial insurance coverage law, an improvement over the last five years. However, only 10 states offer true payment parity, which disincentivizes providers to offer it. 

As a result of this complexity, telehealth has been minimally available to consumers until recently. In a 2016 survey, over half of consumers surveyed indicated they wouldn’t use telehealth and 39% said they hadn’t even heard of it. 

Historic Resistance to Telehealth  

Payers and other entities have historically resisted adopting measures that would expand telehealth adoption by limiting reimbursement and the number of eligible procedures as well as enacting various provider restrictions. A 2018 hearing regarding a Connecticut telehealth bill illustrates the concerns about payment parity. The legislation was supported by providers, but payers and employers opposed the payment provisions citing their desire to negotiate reimbursement themselves as well as arguing that telehealth should fundamentally be a lower cost option. 

A more recent debate holds state medical boards responsible for holding back telehealth progress with their role in continuing to forward credentialing, cross-state and established relationship restrictions. While concerns about malpractice and liability are valid, it’s difficult to say if patient safety is more at risk with telehealth. 

The same argument holds for potential fraud. Though the telehealth industry argues virtual visits are no more susceptible to fraudulent activities than other healthcare encounters, regulators hold that these restrictions are necessary guardrails because of the increased capacity. As one official with the HHS Inspector General’s Office states, “There are unscrupulous providers out there, and they have much greater reach with telehealth. Just a few can do a whole lot of damage.” Health plan SIUs likely will need to adjust metrics currently used to find fraud in in-person encounters, as legitimate telehealth claims may look like previously “impossible visits” regarding provider capacity and geography, for instance.  

Telehealth Benefits During the Pandemic  

The novel coronavirus pandemic has quickly demonstrated the significant benefits of telehealth – both for patients and providers – and thus its market viability. While the pandemic has accelerated telehealth use, one survey indicated that telehealth was already beginning to really take hold with over a third of Millennials and Gen Xers taking advantage of virtual visits. The survey also demonstrates the potential of telehealth, noting that, “based on actual claims costs and coding over the two-year study, approximately 71% of convenience and urgent care visits could have been virtual visits, saving … $3.8 million, or 45% of allowed costs.” 

story out of Pennsylvania illustrates telehealth’s unique benefits for the management of chronic disease, especially for an area with a huge rural and elderly population. Telehealth visits for the region’s largest healthcare provider jumped 3700% from early March to late April. While there were technical challenges for both patients and providers in the beginning, “the satisfaction rate among patients is remarkably high.” They are working on documenting the outcomes during this period to prove the technology’s viability for long-term use, which may be particularly useful for health plans looking to expand risk-based contracts. 

Recent surveys also reveal the pandemic’s impact on physicians and their response. One showed that in-person healthcare visits were down by 67% while overall visits decreased by 54%. However, of the total ambulatory practice visits, 30% were delivered through telehealth, and half of physicians now offer telehealth, up from only 18% two years ago. With 20% of surveyed primary care practices at risk of permanent closure due to the pandemic, many are turning to telehealth to provide continuity for patients as well as to bridge the financial gap. As one physician noted, “The process allows them to keep open that virtual front door in a meaningful way.” 

Telehealth Moving Forward  

So, what’s the fate of telehealth post-pandemic? Bipartisan legislation introduced in October 2019, the CONNECT Act, aims to reduce barriers to telehealth in Medicare, so there is existing support. Additionally, the current situation presents CMS, state Medicaid administrators, state medical boards, and commercial payers alike with several considerations. 

Now that consumers have been able to experience the convenience of telehealth for themselves, they are unlikely to desire a return to the “old way.” Even the elderly population has taken advantage of the safety and flexibility offered by virtual care from their homes. And, combined with payers’ historic focus on digital technology that supports member satisfaction initiatives, health plans may be open to extending telehealth coverage now that consumers are embracing it. 

In addition, more providers have invested in telehealth capabilities to support operational continuity, which reduces infrastructure barriers and promises to mitigate the foretold provider shortage. Because the novel coronavirus has put undue stress on the physical and operational health of providers, continuing the relaxed telehealth regulations indefinitely may prove to be the right move. 

This situation provides an ideal proving ground to test how payment parity and minimizing restrictions affects patient care. If all proceeds without dire consequences, it will be difficult to put the genie back in the bottle.  

Health Plans Turn to Pareo  

Expanding telehealth coverage can no doubt add complexity to an industry that is already shouldering a great deal during this time. Adding to the significant administrative burden of health plans and providers is unsustainable. During the pandemic and beyond, health plans can no longer deny the numerous benefits of digital transformation. Advanced payment integrity technology platforms like Pareo allow payers to support rapidly changing provider contracts and payment policies and seamlessly engage with providers.   

While the expansion of telehealth at such a rapid pace is a new development, most payers have long-anticipated a shift to digital care to improve patient access and intervention for value-based care initiatives and other healthcare cost savings measures. However, health plans who are not agile in data sharing, accessing relevant business insights, or even vendor management may struggle to modernize operations fast enough.   

Administrative burden is a problem that most payers have yet to solve, and the quick expansion of telehealth is sure to exacerbate the issue. Pareo is unique in that it not only unites disparate systems and automates workflow (solving many efficiency problems), but our payment integrity technology also sets the stage for health plans to own the core operations that power revenue. Our clients have seen up to a 10x return on investment, with efficiency gains estimated at 25-50%. 


Talk to ClarisHealth about how Pareo®, a total payment integrity platform, is driving innovation at health plans.