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. 

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

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

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

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

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

Overlapping Medical Record Requests Begone

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

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

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

Harmony: Vendor Coordination + Provider Communications

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

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

Enter Pareo Clinical.

Pareo Clinical: Eliminates Risk Around Medical Record Requests + Retrievals

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

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

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

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

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

5 Keys to Help Your Health Plan Focus on 2020

5 Keys to Help Your Health Plan Focus on 2020


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

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

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

1. Start with last year’s plan

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

2. Keep your long-term plans flexible

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

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

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

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

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

4. Prepare for innovation cycles

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

Transforming business models

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

Investing in dynamic technologies

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

Workforce training and talent

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

Dynamic data governance policies and practices

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

Risk management

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

5. Master these two skills essential to futurist planning

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

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

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

Checking in: How to offer vendors a concierge experience

Checking in: How to offer vendors a concierge experience

When we created Pareo®, from its inception we knew vendors would be an important stakeholder in the payment integrity ecosystem. As our payment integrity solution has grown (in many ways, shaped by our incredible clients), it has cemented our belief that focusing on payment integrity suppliers is an important way we can better meet the needs of modern health plans. 

As you likely know, including more vendors in your payment integrity operations is likely to boost your recoveries. Yet, managing relationships with them can feel burdensome when we don’t have access to the right tools or information. That’s why we’ve set out to give those suppliers working with Pareo what I like to call the “Ritz Carlton experience.” 

That’s because — as with every relationship — you get from your vendors what you put in. We want to enable our clients to give their suppliers a five-star experience when working together. We developed Pareo Supplier Optimization to give your PI department all the tools they need to work effectively with vendors by boosting transparency, increasing engagement rates and contributing to improved recoveries. Perhaps you’ve discovered for yourself the value Pareo brings but you’re still looking for other ways to increase vendor experience. If so, read on.

Request a brochure and learn more about Pareo’s Supplier Optimization functionality.

7 Ways to Treat Your Vendors as Well as Customers

So much focus has been given to improving member satisfaction at health plans (with good reason — it’s important). But your vendors are such an important part of health plan operations, why not focus on their satisfaction as well? Are you giving them everything they need to help you maximize your return on investment? 

As you look to technology to improve supplier relationships, be sure to cover all your bases by striving for these 7 important functions that can lead to a better vendor relationship:

1. Share goals. The most successful vendor relationships function more like partnerships, rather than transactions. You both have the potential to provide greater value to the other.


“Vendor management is not negotiating the lowest price possible but constantly working with your vendors to come to agreements that will mutually benefit both companies.”



2. Communicate clearly and consistently. Transparency allows everyone to be on the same page. Both sides should be able to easily provide access to information on project progress — without asking for silo-ed status updates. “There may be issues between you and your vendor, but constant communication and a dedication to continuous improvement will make the difference,” writes Brian Fielkow.


3. Plan ahead. Set expectations on service level agreements, contract terms, etc. Surprises and emergencies are inevitable, but should be the exception with a well-thought out vendor plan. 


4. Pay on time. Their invoice should never be a surprise. Paying in a timely manner communicates to vendors that their work is valued.


5. Provide process training for your vendors. They have their area of expertise, which likely does not include “how you do things.” Set them up for success by bringing them to the table.


6. Be reasonable and accountable. Vendors are third-party stakeholders that rely on you in order to perform at their best. Likewise, you rely on them to meet their goals. Respect is a key part of the vendor-payer relationship and for health plans, that means being reasonable and accountable in vendor relations.


7. Make the most of meetings. The quarterly business updates that characterize most third-party payment integrity vendor relationships can be more valuable than out-of-date “status updates.” They can be meaningful strategy sessions, if the day-to-day communications are taken care of.

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

Modernizing communication with providers

Modernizing communication with providers

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

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

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

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

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

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

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

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

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

Where does Pareo® fit in? 

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

Pareo enhances Provider Communication efforts through: 

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

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

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