Will AI finally make good on its promise to healthcare?

Will AI finally make good on its promise to healthcare?

Artificial Intelligence continues to be a much-hyped “trend” for healthcare technology but adoption lags. Here’s what AI is — and isn’t — and why this may be the decade it takes hold for health plans.

When IBM Watson, the AI supercomputer created by IBM, won Jeopardy! and then moved on to a career in healthcare (via Watson Health in 2015), the industry was abuzz with possibilities. Sci-fi speculation ran rampant and then fell flat, when in 2017 it was revealed that IBM Watson wasn’t exceeding — or even meeting — expectations. AI capabilities were muddied by the hype, and adoption of the technology continues to be slower than expected. 

However, AI is a powerful force in technology and crucial to disrupting the healthcare industry. And in 2020, AI is poised to improve rapidly (it was recently reported that Google’s AI system was more accurate than experts in finding breast cancer).  Let’s explore what AI is — and isn’t — and why it’s here to stay. But first, a few definitions:

Artificial Intelligence: Intelligence applied to a system with the goal of mirroring human logic and decision-making. AI is utilized for the purpose of successful knowledge acquisition and application, which it prioritizes over accuracy. AI simulates intelligence (the application of knowledge). It is a combination of technologies, comprised of machine learning and predictive analytics.


Machine Learning: An application of AI that allows a system to learn on it’s own. ML learns from data, and it aims to increase accuracy (success is a lesser concern). ML simulates knowledge. Source


Data Mining: Unstructured data that is collected, often for the purposes of data analytics.


Predictive Analytics: Data that has been collected is utilized to try and predict behavior/outcomes (often called Data Science). To analyze data, it is routed into a report, at which point humans or artificial intelligence apply multiple factors to make predictions about expected outcomes. Predictive Analytics often implies that a machine has performed the analysis and offered a prediction (rather than a human).

Is 2020 the year for AI?

Experts predicted that AI would grow rapidly in 2019, but adoption waned. Additionally, a growing number of consumers (and regulators) are becoming uncomfortable with “black box” AI. Forbes points out, “As humans, we must be able to fully understand how decisions are being made so that we can trust the decisions of AI systems. The lack of explainability and trust hampers our ability to fully trust AI systems.” 

In all industries, AI can vary greatly by product and generalized claims can be misleading. In healthcare, relying on AI before explainability has been satisfied is a large risk. Yet, creators of the algorithms that power AI will often refuse to disclose how they work, citing proprietary information.  

The lack of explainable AI is a huge hurdle to applying (and approving) the technology’s use in clinical care settings. For example, when a study showing that AI could interpret risk of patient death based on ECG test results with greater accuracy than physicians, without being able to explain how it did so, doctors expressed amazement — and discomfort. “It’s still unclear what patterns the AI is picking up, which makes some physicians reluctant to use such algorithms.” Furthermore, lawmakers are still grappling with how to regulate the technology, and those outcomes can play a significant role in health tech.

Early adopters in the healthcare payer sector understand the benefits and risks associated with AI all too well, and skepticism of vendor claims of AI is high (and rightly so). However, the value of AI is steadily increasing, and AI compute has been doubling every three and a half months. In fact, 2020 was a remarkable year for the advanced technology. The AI Index 2019 Annual Report calls out the following technical performance achievements: 

  • In just a year and a half, large image classification systems are training much faster on cloud infrastructure, down to 88 seconds in mid-2019 from three hours in late 2017. Costs to train these systems have also fallen.
  • Progress on natural-language processing classification tasks is “remarkably rapid,” though performance on NLP tasks that require reasoning has not kept up

If investment dollars are any indication, AI technology will continue to boom. Last year, global private investment dollars in AI topped $70 billion: 6.1% of those investment dollars were attributed to drug, cancer and therapy while 3.9% was given to fraud detection and finance. 

How AI is Applied to Healthcare Technology

AI is expected to permeate every facet of healthcare, with annual spending on advanced technology estimated to be more than $34 billion in 2025. But AI is not a solution in and of itself; it’s an application of various methodologies, and this causes some confusion. The current applications of AI in healthcare are narrow and highly functional, especially given that the quality of the technology itself can vary based on the vendor.  

Some current applications of AI for health plans include: 

Fraud, waste and abuse solutions

Value-based care initiatives

Claims Management

Coordination of Benefits

Predictive Analytics

Potential applications for advanced technology are much broader and include increased efficiencies and improved patient outcomes. Surveyed physicians have reported that AI is already improving the time they spent with patients, and 78% of healthcare business leaders say that the advanced technology “has helped drive workflow improvements, streamlining operational and administrative activities and delivering significant efficiencies toward transforming the future of healthcare.” Yet, explainability may hamper some AI adoption in the coming year. 

“Differentiating on price isn’t going to be the way to win in healthcare; differentiating on experience will be.”

Heather Cox, Humana’s chief digital health and analytics officer, on why Humana is investing in AI to enhance patient experience

In the coming year, healthcare payers will see technology disruptors enter the market. For many plans, a selection of effectively managed vendors will be the most effective strategy to drive ROI, though health payers will have to be careful of hype, particularly from tech vendors who lack industry experience. What works for one sector — say, finance — does not easily translate into healthcare, which is often more complex, more heavily regulated, and more data sensitive. 

Health payers will need to see all the moving parts of their tech ecosystem, including real-time metrics on vendor performance, in order to be able to see vendor lift, even if AI capabilities are touted. Increasing visibility across disparate departments and retrieving data from silos are exactly the type of improvements that show AI at its best. 

How Your Health Plan Can Utilize AI

You might think that being a fax/email/spreadsheet organization means your health plan is woefully out of date, but you might not be as behind as you fear. While AI can offer much-needed technology advantages to health plans, it isn’t capable of solving all payment integrity problems on its own. If a technology vendor is touting its AI capabilities, the solution should be more than a “black box of mystery.” You can and should deeply question and demand specific capabilities in regards to AI from a technology vendor. 

That said, AI is a crucial technology for health plans to adopt or expand upon within their organization. The massive amounts of data inherent in healthcare systems have presented a problem for the industry as a whole. With AI, data can be mined and utilized to harvest useful insights. Historical data can be loaded into the system and utilized alongside real-time data for predictive analytics. Pareo® offers multiple applications for AI as part of a broader “one-source” system insight platform for health plans and payers.

Despite IBM Watson falling short of expectations, AI technology will only continue to improve and the past year has proved that. At this stage, AI technologies may be more commonplace than you realize, but the true abilities of artificial intelligence vary between technology vendors. The most powerful way to harness AI capabilities is when they are applied as part of a broader solution, an advantage provided by an integrative platform like Pareo®

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

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Will AI finally make good on its promise to healthcare?

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2020 Vision: A look at Healthcare Payer Technology Trends

2020 Vision: A look at Healthcare Payer Technology Trends

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Top 10 Reasons Health Plans Choose Pareo

Top 10 Reasons Health Plans Choose Pareo

It’s almost 2020, and forward-thinking health plans have a choice when it comes to total payment integrity solutions.

From smaller regional plans with 100k members to large national health plans with millions of lives covered, Pareo scales to accommodate all needs. Here are the top 10 reasons that health plans choose Pareo:

1. Reduce Administrative Spend

Health plans often seek out Pareo as a total payment integrity solution that eliminates administrative complexity, reducing overall spend. It’s estimated that 10% of all health care spending in the U.S. is wasteful, attributed to administrative costs that would be eliminated by more efficient processes.

The burden of cumbersome, manual admin processes lead MCOs to miss timely provider payments, tightening their provider network and placing an unnecessary burden on patients and providers.

For managed care organizations (MCOs), the cost to coordinate benefits is estimated at 12% of a health plan’s entire spend. ClarisHealth’s solution simplifies and automates workflows, allowing our clients to quickly optimize operations and reduce costs for coordination of benefits.

2. Optimize Relationships with Business Partners

For many health plans, bringing on more business partners to improve recoveries is a top-level goal. However, the inability to see the “bigger picture” makes it extremely difficult for health plans and their business partners to plug in easily or operate at maximum utilization. Pareo is able to optimize relationships with business partners, allowing health plans to grow their recoveries and easily coordinate goals with third-party payment integrity partners.

Pareo is able to benefit both health plans and business partners by offering easier onboarding, real-time feedback, fast turnaround on new concepts, and multi-beneficial sharing of information that’s customized to each business partner. We view our technology as a crucial connection that improves technology capabilities for health plans.

3. Eliminate Work Silos

Work silos are a byproduct of company structures, based on natural development of ideas and workflows within departments. However, it’s widely understood that these silos prevent the overall growth of an organization. The healthcare industry in particular has suffered from data siloing in large part due to manual, inefficient work processes.

As health plans seek to centralize their payment integrity efforts and break down data silos, they turn to Pareo. Our total payment integrity technology supports initiatives that break down silos, such as change management techniques, by culling system-wide data and presenting it through a single portal.

4. Organize Big Data

Data is an integral part of health plan operations, but many organizations struggle with the task of managing so much information. Pareo assists with process digitization, allowing our clients to move beyond spreadsheets and into a more dynamic platform.

When managing data is no longer of primary concern, health plans can move into activities that generate a higher return on their investment. Faster decision making and utilizing predictive analytics (both available with Pareo) can take a standard data report and turn it into actionable insights — all in real-time.

5. Modernize fraud,  waste and abuse mitigation

Health plans that want a more robust fraud prevention program seek also to address waste and abuse, a holistic approach that keeps a tighter cap on improper payment rates. Our clients use Pareo to …

  • Analyze post-adjudicated and post-pay claims data (useful as the Federal government is starting to look at how health plans do this)
  • Intelligently flag potential waste and abuse claims
  • Automate claims and auditing workflows
  • Introduce the application of AI technology 

Waste and abuse actually outsize fraud, but the terms are perceived as more ambiguous, resulting in the use of limited technology rather than broader solutions. Health plans may mistakenly think they’ve got payment integrity “covered” when they really only have fraud-prevention technology in place. By addressing a health plan’s entire payment integrity continuum, Pareo helps our clients transition more post-pay activities to prevention. 

6. Improve Provider Engagement

As more providers collect payment upfront and more payers look closely at member satisfaction, the intersection between the two has narrowed. Proactive health plans are seeking to improve provider engagement with the understanding that doing so has a direct effect on member satisfaction rates, and they’re choosing Pareo as the technology that supports this.

Keeping your health plan’s providers happy will also keep your members satisfied.

By automating activities, providing access to necessary claims documentation, and removing redundancies, Pareo is able to significantly minimize provider abrasion. We are firm believers in tracking a Net Promoter Score with your health plan’s providers as way of measuring improved engagement.

7. Control Claim Spend

Why settle for 1-2% as the rate of return on claims when you can get up to 10% by using Pareo? Total system visibility is required in order to control claim spend, but without understanding what’s possible, many health plans settle for less.

Overspending is a huge problem in healthcare, accounting for about $1 trillion of total healthcare expenditures in the U.S. With Pareo, you can actively track your spending on claims in real-time, allowing your health plan to quickly correct course. Excessive administrative costs, missed prevention opportunities, and unnecessary services are all causes of overspending. Pareo’s advanced analytics module allows health plans to gain traction on claim spend, improving recoveries and furthering ROI.

8. Access a community

I think by now many of us understand that organizations suffer when information isn’t shared. Health plans are seeking technology solutions that afford them access to shared expertise. While accessing a group of people who are looking for the exact same solutions that you are is incredibly valuable, another perk of being a member of a community of users is reaping the benefits sown by early adopters. Those first movers are often working closely (whether they know it or not) with QA to ensure your software experience is all the better. In addition, first movers can easily become super users and a source of community knowledge for other members.

Numerous health plans — of all different sizes, with different lines of business, etc. — all working within a common platform is a feature of the SaaS model, not an accidental by-product.

True, health plans have not historically unified on matters of business practice. At a time of rapid disruption, it’s helpful to realize that collaborative organizations have proven more effective. Real benefits of collaboration among departments, with other stakeholders and even with other health plans include: reducing administrative costs, fast-tracking innovation, and improving working relationships.

9. Integrate fragmented systems

Disparate data systems are being abandoned, but as API integration becomes the norm, many health plans are learning not all technology is created equal. With the declaration of APIs as the “better” solution for interoperability, health plans will need technology ecosystems that support integration and allow them to connect and visualize data in a meaningful way. 

The ability for a health plan to share data is mandated — and will continue to be closely watched and regulated once the Proposed Rules become final. For many, the ability to meet or exceed interoperability rules brings health plans to a “disrupt or be disrupted” type of choice. 

10. Transition more efforts to prepay

Post-pay concepts in a prepay environment? That’s just a pipe dream for health plans. Or is it? Payment accuracy isn’t a problem that’s going away anytime soon, but pay-and-chase is expensive for health plans to maintain. Leaders are looking for more ways to prevent improper payments from ever occurring but in order to do so, comprehensive insight and management is needed. 

ClarisHealth works with health plans to develop a specific implementation and use plan for Pareo that meets and often exceeds the goals you’ve outlined for your plan. The ability to transition more claims to prepay requires transformative technology solutions that can integrate disparate systems, such as those offered by Pareo. 

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

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Will AI finally make good on its promise to healthcare?

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Artificial Intelligence continues to be a much-hyped “trend” for healthcare technology but adoption lags. Here’s what AI is — and isn’t — and why this may be the decade it takes hold for health plans. When IBM Watson, the AI supercomputer created by IBM, won Jeopardy!...

2020 Vision: A look at Healthcare Payer Technology Trends

2020 Vision: A look at Healthcare Payer Technology Trends

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Your FWA solution may not be as modern as you think.

Your FWA solution may not be as modern as you think.

The package may have changed, but the truth is most FWA solutions are still relying on legacy technology. 3 ways to spot the difference.

To prepare for the advancing disruptions to healthcare, most plans we speak with have made some progress towards digital modernization. Often, they’re starting with evaluating their current technology vendors, except for one glaring oversight: fraud, waste and abuse solutions. Did you know, those on the market today are by and large relying on 30 to 40 year old technology? Even many “new” solutions are old products dressed up in new packaging. 

While it can be comfortable to use products we are most familiar with, the problem is, the way we’ve always done things just won’t cut it anymore. It’s very possible that with each passing year, your tried and true technology isn’t quite so effective. Recent advancements in automation and predictive analytics have yielded modern FWA solutions that promote transparency and integration with other systems. 

Got a hunch the FWA solution you’re using may not be as modern as it should be? Get ready to evaluate the evidence for the three big signs of outdated technology. 

1. Reporting Struggles

Your health plan’s FWA solution may be legacy if… it relies solely on rules-based reports. While rules-based reporting is foundational functionality that is still useful, it only addresses known schemes. Fraudsters are changing up their schemes more often than what legacy solutions can keep up with, meaning this outdated approach will leave health plans in a precarious place (and do you really need to combat more false positives?). 

Rules-based reporting is not multi-dimensional and this impairs an investigator’s ability to ascertain legitimate leads. What’s more, some algorithms are actually rules-based which holds them back from being the robust solution so desperately needed in this industry. “Traditional analytics solutions built on relational databases aren’t up to the task,” writes Fierce Health Payer. That’s because fraud schemes are growing increasingly complex, and flat views of them will make legacy FWA solutions a drain on the SIU’s limited resources.

Another reporting issue? The “pull” approach. If your reporting lags and is centered around knowing the right questions to ask, you aren’t accessing the bigger picture. In comparison to a robust data analytics system, pulling reports does not prioritize issues. “Payers should look for platforms that visualize data in an informative way, develop insights using financial big data, and support predictive analytics capabilities,” writes Health Payer Intelligence.

2. Too Little Information on Providers

Lacking visibility into providers? You’re not alone, and it’s yet another sign of older FWA technology. The SIU is by and large missing the ability to efficiently and effectively access provider details, which may range from a particular provider’s associated practices to a lack of visibility into provider education (and no way to measure efficacy of that education). 

When investigators lack visibility into provider data, efforts to obtain that information come at a cost. And while manually communicating to determine provider details or check in on remediation programs, health plans run the risk of a greater cost in the form of provider abrasion. While most fraud schemes may happen at the provider level, very few providers are fraudsters. Communications from the SIU have to be considerably more precise and streamlined than what legacy technologies may afford.

According to NHCAA, “the majority of healthcare fraud is committed by a very small minority of dishonest health care providers.”

Research by the Government Accountability Office (GAO) shows the following trends in provider fraud schemes: 

  • Falsifying claims or diagnoses
  • Participating in illegal referrals or kickbacks
  • Prescribing unnecessary medications to patients
  • Upcoding for expensive, medically unwarranted services

3. Limited to Pay-and-Chase

Health plans are weakened without the proper tools to navigate away from pay-and-chase and towards prevention. But the standard approach to FWA is chasing down improper payments, rather than preventing them. If your current FWA solution does not allow you to effectively detect the risk of an improper payment before that claim is paid, you’re likely using a legacy system.  

Now that the technology is improving, more sophisticated approaches are available. These preventive solutions tend to rely on predictive modeling, but be warned the quality can vary greatly. If a vendor you are considering uses buzzwords like “AI” and “machine-learning” to describe their product functionality, you should know these terms are often used incorrectly. 

It behooves SIU and Compliance teams to drill down into vendor claims of advanced technology to see how predictive capabilities function. Are they dynamic and do they rely on good data? Are they using the right set of metrics? And perhaps more importantly, can these advanced technologies integrate intelligently with a plan’s overall payment integrity processes? Because more and more, effective FWA detection is reliant on more than the SIU. 

So your FWA solution is outdated, now what? 

If you think your FWA solution is no longer up to the task, it may be helpful to focus first on what your organization needs from a technology provider. A true FWA solution is one that gives investigators the tools they need to separate the signal from the noise, quickly and effectively. Advanced integrative technology that provides broader access to real-time data will allow your health plan to modernize the SIU. 

Partner to Make 2020 the Best Year Yet

Talk to ClarisHealth about how Pareo® can improve your health plan’s payment integrity processes -- no matter what the future brings.

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

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

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

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

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

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

ONC’s Information Blocking Rule Raises “Significant” Concerns

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

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

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


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

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

Proposed Information Blocking Rule

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

Proposed Interoperability Rule

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

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

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

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

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

Supporters Say Benefits Outweigh Risk

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

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

Where to from here?

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

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

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

Partner to Make 2020 the Best Year Yet

Talk to ClarisHealth about how Pareo® can improve your health plan’s payment integrity processes -- no matter what the future brings.

An Aggressive Plan to Move your Claims Recovery to Prepay Status

An Aggressive Plan to Move your Claims Recovery to Prepay Status

Transitioning more payment integrity operations to internal prepay is more than just a pipe dream for health plans

Transitioning prepay. It’s the holy grail for health plans — and viewed as equally unattainable. And, in the not-so-distant past, this viewpoint would have been correct. But now, with the assistance of innovative technologies, health plans can take an aggressive approach to transitioning claims recovery to an internal prepay model. Here’s a look at the challenge of transitioning to prepay, the solution we propose, and why your health plan can’t continue the business-as-usual efforts in this area. 


The “Challenge”

Historically, health plans applying post-pay concepts in a prepay environment have been mutually exclusive ideas

In today’s market, it’s essential for health plans to get a handle on payment accuracy. But, without the proper technology tools in place, it’s difficult for payers (and other healthcare stakeholders) to gain true visibility into their operations. In the case of third-party technology suppliers, who rely on their partners to perform at peak level, these murky waters may prove especially hard to navigate. 

Without comprehensive insight and management, it is very difficult for payers to move the needle on claims recovery. Especially when attempting to shift claims from post-pay to prepay, though doing so promises improved efficiencies and higher rates of return for health plans. We see two common barriers to making this shift:

  1. Even if your third-party vendors possess the kind of technology that would enable you to move more claims to prepay resolution, health plans have no ability to store the most successful concepts and apply advanced analytics prepay. 
  2. Even if you do have insights, limited data analytics resources prevent you from taking full advantage of advanced technology.

You may know that some health plans have been able to shift claims recovery efforts to internal prepay activities, but do you fully understand how? In part, successful plans achieve this by breaking down data barriers. With the right solution in place, payers can actually overcome the limitations that poor data visibility place on them. 


Why Prepay is an Urgent Concern

Health plans need the efficiencies that comprehensive payment accuracy technology brings, and prepay is an opportunity to make quick strides. 

We get it. You have a laundry list of to-do’s, all vying for top priority. Digital-first strategy, member experience improvements, optimizing costs and outcomes — these are all important goals. But, it could be that a focus on claims recovery gives your health plan the breathing room it needs for these significant investments. And as professional program integrity problem solvers, we think a shift to prepay is a valuable opportunity for health plans looking to gain traction on aggressive payment accuracy targets. 

We aren’t alone in suggesting a technology solution to improve claims recovery (and management in general). Earlier this year, Fierce Healthcare pointed out, down to the dollar, how much it costs a payer to manage claim inquiries. “When a provider contacts a payer to check a claim status, it takes an average of 14 minutes and costs the provider $7.12… multiplied by millions of requests each year, the time and money add up. In 2018 alone, providers made 173 million claim status inquiries by phone, fax or email.” 

Investing in data analytics is a growing trend. In fact, 60% of surveyed health executives say they are investing more in predictive technologies in 2019. Claims recovery will continue to be an important facet of your health plan’s payment accuracy operations. With the right solution in place, the ability to shift to internal prepay concepts will be in your hands. 


The “Solution”: Pareo® is How

With a centralized solution like Pareo in place, everyone can get on the same page, including vendors and other departments responsible for payment accuracy. 

It may take time, it may necessitate a change in how you do things, but we believe all health plans have the opportunity to deploy a centralized solution for payment accuracy (and reap the benefits). Here’s an idea of how a PI solution like Pareo works from a holistic vantage point to quickly turn around recoveries at your health plan: 

Our team works with you to develop a specific implementation and use plan for Pareo that meets (and often exceeds) the goals you’ve outlined for your plan. If shifting to prepay cost avoidance is a goal of your health plan, Pareo is the comprehensive solution that will help you get there.

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

Data Interoperability Solutions Start with the Consumer

Data Interoperability Solutions Start with the Consumer

Why a consumer-first mentality may be the best way to comply with Information Blocking rules.

If we were to ask you what your health plan’s digital strategy is, would you have a ready answer? Don’t worry: this isn’t a pop quiz and we aren’t grading you. We can’t say the same, however, for the GAO. In a  push for increased data transparency, the Information Blocking Rule will affect how health plans operate. But let’s not lose sight of the true goal of this initiative: easier consumer access to their own healthcare data. We know your organization is already passionate about member satisfaction. But here’s why approaching your information sharing strategies from a consumer-first mentality may put you ahead of the curve.

Don’t forget: Pareo® is your key to successfully complying with this and other transparency initiatives as it can integrate with varied healthcare stakeholders through API.

Digital Strategy Relies on the Big Picture

Your response to the proposed Information Blocking Rule will depend on your health plan’s roadmap to digital transformation. Though the proposed rule may motivate or change your health plan’s response to the digital age, chances are you’ve already begun to introduce new technologies into your IT ecosystem. Unfortunately, healthcare as a whole is woefully behind other industries when it comes to digital transformation: A 2018 survey by Ecoconsultancy and Adobe found that healthcare companies were digitizing at half the rate of other industries (7% compared to 15%). 

Even though health plans are entering a sphere where their success will become increasingly reliant on their digital strategy, no one seems to have the key element needed for digital transformation: access to the bigger picture. As in, not one stakeholder in the healthcare continuum has a full grasp on the data. Instead, health plans only have health information related to claims data (at best). Providers don’t have point-of-care access to health information. And consumers – the group driving digital transformation – are having a hard time getting their records at all. 

Consumer access to patient data is the entry-point into this problem. It is the goal that the proposed Information Blocking Rule was built on, and it correlates nicely with other industry goals (improved care, member satisfaction, value-based models). What role, then, do health plans play in providing members access to their data? A big one, according to the GAO. 

The proposed rule “calls on the healthcare industry to adopt standardized application programming interfaces (APIs), which will help allow individuals to securely and easily access structured EHI using smartphone applications.” APIs, like those used by your technology vendors, integrate with components of your health plan data to work effectively. 

Currently, most health plans have no digital management tool to take advantage of available API integrations. But Pareo is the first and only payment integrity technology solution that can plug in to every API in your ecosystem to provide an unparalleled advantage: real-time access to the bigger picture. 


How Pareo Enables Consumer-First Digital Strategy

Health plans are being asked to do a lot. Healthcare is bracing for an unprecedented level of disruption that will require health plans to innovate, and quickly, all while complying with a level of transparency previously unachievable, maintaining strict data security standards, and cutting costs. The concerns and demands surrounding technology can easily send a health plan down a rabbit hole. 

It’s easy to say that the success of technology in modernizing other industries needs to be applied to healthcare. But healthcare is both a public service and a business, highly regulated and running on tight budgets, which means many in the industry wait to implement solutions until they are demanded to do so. It doesn’t have to be that way. 

Consumers require access to their electronic health information. In order to participate fully in the new era of data access, health plans will need secure, free-flowing integrations with providers, payment integrity suppliers, and technology vendors. More importantly, a health plan will need a secure way to manage these digital relationships. At its core, Pareo was designed to do just that, to help health plans swiftly move from having a very narrow view of information, to seeing data visualizations in real-time. This single, powerful transformation will affect every aspect of your payment integrity operations. 

Tracking the proposed Information Blocking Rule

The public comment period for the Information Blocking Rule has closed and lawmakers have suggested delaying a vote on interoperability rules. We are tracking the subject closely and will continue to publish relevant commentary as new information is released: 


Full access to your health plan’s data and digital relationship management primes a health plan for greater success. Pareo is a technology solution that also allows health plans to innovate on existing technologies, applying AI and machine-learning intelligence to data reporting functionality. It also reduces administrative complexity by automating tasks and intelligently flagging claims, freeing up your employees to focus on other, higher-value tasks. Like making members happy, shifting claims to pre-pay rather than post-pay and adding more technology vendors to maximize recoveries. 

That’s the power of Pareo. 

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