The Strategy Nearly Every Health Plan Considers: Outsource vs. Insource

The Strategy Nearly Every Health Plan Considers: Outsource vs. Insource

Slim margins, fewer resources, and consolidation have made it harder for health plans to compete. Could balancing outsource vs insource efforts accelerate their goals? 

With shrinking margins, fewer and fewer internal experts, and increasing consolidation, health plans may find it harder than ever to compete.  These limitations give rise to unique challenges, however unique solutions have emerged to overcome even the most insurmountable hurdlesTo ensure your health plan thrives in the current healthcare climate, you may have considered the relative benefits of outsource vs. insource strategies in their potential to transform your payment integrity results.

Health Plans Face Challenges with Scaling 

We hear regularly how legacy technology, “less is more” mentalities and lack of resources are top of mind for many health plans. The enormity of these struggles seemed to accelerate alongside the influx of millions of newly insured Americans that accompanied the passing of the Affordable Care Act. In its wake, many health plans discovered their largely manual processes could not scale to meet the growing concern around improper payments and wasteful healthcare spending 

Time has shown that the pace of change hasn’t stopped since. Even before the COVID-19 crisis hit, a stream of regulations continued to overwhelm the limited resources at most health plans. Compliance with the information blocking rules, for instance, can distract from other high-value activities – no matter the potential long-term benefits of both initiativesIncreased consolidation makes it more difficult to compete, while heightening the necessity to do so. Perhaps now more than ever, lack of resources continues to be a major barrier for many health plans.  

Altogether, the writing is on the wall: the future of healthcare requires claims processing modernization, data aggregation, information security and the ability to lead the transition to alternative payment models and gains in population health improvements – all with great urgency, says Healthcare FinanceHealth plans understand these directives and acutely feel the need to catch up, but inadequate technology, staffing shortages, competing capital projects, and combinations of these and other factors hold them back from progressing at the desired rate. 

 

Weighing Outsource vs. Insource 

Whether it’s transitioning more efforts prepay, going beyond compliance to proactively address FWA, or streamlining workflows to reduce administrative complexity, scalable processes that hold the potential to transform results are accessible to all payers – not just heavily-resourced health plans. But what offers the best path to maximizing your health plan’s cost containment goals? Let’s explore outsourcing vs. insourcing your payment integrity efforts. 

How does payer outsourcing work? 

Payer outsourcing involves a health plan contracting with a third-party vendor for claims processing and other functions. In this model, an outside group of focused experts perform what otherwise would be an “overhead expense” in the form of technology investiture and staffing/resources. As the pressure to optimize has increased, payer outsourcing has expanded beyond business process outsourcing (BPO) to include innovative technology and real-time resources that don’t require an up-front capital investment.  

Health plans are increasingly outsourcing some or all parts of their payment integrity program, including FWA, coordination of benefits, itemized bill review and more – for prepay and post-pay. Just look at Oscar Health, a startup health insurance company that made news relying on an insourced/outsourced model (along with advanced technology) to provide a more efficient healthcare experience.  

“The end goal is to process claims efficiently so doctors spend less time hunting down payments for the care they already gave, and reduce errors so consumers never have to deal with denied claims or paying for services they never received,” writes Oscar Health. 

Impressively, if your health plan is significantly under-resourced, an outsource to insource model can help you achieve serious traction in revenue gains without hiring additional personnel, adding expertise or immediately acquiring technology on your ownIt’s a strategy that many innovative startups rely on, and one that also works well for health plans at all stages of maturity.  

How can I effectively insource? 

Insourcing in this case, simply put, involves conducting payment integrity processes with your health plan’s own resources. If your health plan has pursued an internalization strategy in the past without much success or with limited gains, you aren’t alone. Legacy business models that rely largely on manual processes hinder innovation. But acquiring an advanced technology platform designed specifically for health plans can help you scale your internal resources. 

Starting with foundational functionality that addresses your most pressing need first ensures ROI, smooths user adoption and makes the most of limited resources. Dramatically reducing manual processes and achieving mutual value with suppliers allow you to reduce your administrative overhead and tackle payment integrity in the most cost-effective manner. 

Especially if you can acquire technology that works out-of-the-box for your needs and accommodates configurability without development, you can accelerate your speed to value. No matter your motivations, the potential for doubling or tripling your recoveries creates a solid case for insourcing. 

“Under-resourced health plans face unique challenges but benefit from unique solutions that transcend the outsource vs. insource argument. “

The Smart Solution: Start Wherever You Are  

Now that we have taken some time to weigh the outsource vs. insource argument, you might start to realize that elements of both strategies hold potential for your health plan. And that’s not surprising. Even the big national plans only started formalizing centralized payment integrity functions 10 years ago, so there’s still time to catch up and multiple ways to get there. 

The vast majority of our clients find their path lies down a hybrid model of outsource-to-insource or pursuing both concurrently in an optimized combination of the two. For instance, you may find it easier to internalize data mining with the right enabling technology that helps you streamline workflows and realize efficiencies. On the other hand, your health plan may decide to always outsource complex medical records reviews because of the specialized resources it requires.  

Statistics back up our experience with this hybrid approach to payment integrity; claims management – including payer services and product development – holds the largest market share of healthcare BPO. Fortunately, no matter your choice, the first step is the same. “For the same reason you outsource claims processing, find a trusted partner with expertise and advanced technology to ease your payment integrity burden,” says Jason Medlin, vice president of strategy and marketing at ClarisHealth 

A partner and a platform that allows you the flexibility to decide – service by service – whether to outsource or insource based on your cost-benefit analysis will better poise your health plan to scale effectively. Contingency-based relationships, like we use at ClarisHealth, are helpful for under-resourced health plans because they don’t require a large capital investment, which makes payment integrity outsourcing far more turn-key and affordable than you may realize. It also is worth noting that many plans will find it beneficial to move quickly on technology implementation as a way to speed overall time to value. 

 

Get a No-Risk Proof of Concept for Pareo   

At ClarisHealth, we don’t believe the outcome of the outsource vs. insource debate is necessarily binary. Rather, health plans can strategically outsource and insource select payment integrity efforts based on current resources while making a plan to adjust that mix over time to attain crucial internalization goals. We offer flexible delivery models, including an outsource to insource path, to meet health plans where they are.  

Talk to ClarisHealth about Pareo®, our comprehensive payment integrity solution, which makes for a seamless transition to an optimized blend of outsourced and insourced payment integrity.  

Learn More

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

More from Our Blog:

You Don’t Need Rules to Mitigate Healthcare FWA

You Don’t Need Rules to Mitigate Healthcare FWA

Health plan SIUs find deep learning models for fraud detection provide advantages over rules-based tools.   The onset of the novel coronavirus pandemic highlighted a glaring weakness in rules-based FWA systems: the need to develop rules well ahead of their actual use...

3 Ways MCOs Can Prevent Fraud, Waste and Abuse

3 Ways MCOs Can Prevent Fraud, Waste and Abuse

A robust fraud, waste and abuse program at MCOs and MAOs includes three key areas: Technology, Clinical Audit and Investigative capability.

As your health plan grows its fraud, waste and abuse initiatives, there are three areas a strong prevention plan should address. Rather than relying on piecemeal components to combat Medicare and Medicaid fraud, as many health plans do, a comprehensive approach is best practice.

To truly be successful with a fraud, waste and abuse program, you must have three key pieces of the puzzle in place: Technology, Clinical Audits and Investigative capabilities. With all three of these tactics in place, health plans are more likely to increase their recoveries as a percentage of total claim spend. Pareo®, a total payment integrity solution, supports each of these fraud, waste and abuse capabilities.

Risks of Overlooking Common Types of Fraud, Waste and Abuse

Fraud, waste and abuse are three classifications of improper payments, which is a payment made or received in error in a government healthcare assistance program (like Medicare and Medicaid). Improper payments are more broadly combated by a comprehensive payment integrity and FWA program, as simply addressing fraud, waste or abuse alone will still miss some areas of fraudulent or wasteful activity.

According to this article, fraud, waste and abuse investigators typically focus on “two general areas: corruption and asset misappropriation.” They do this by analyzing the large amounts of big data generated by healthcare transactions. But are MCOs and MAOs doing enough in this area?

A recent report found that Medicaid insurer efforts to root out fraud, waste and abuse were disappointing. Major oversights found in their report include:

  • Failure to report offending providers to the state (allowing them to defraud other Medicaid insurers)
  • Failure to recover millions of dollars in overpayments, which could lead to increases in Medicaid rates that are based on fraudulent numbers 

Meridith Seife, a co-author of the report, said, “We are concerned anytime we see evidence that managed-care organizations are not [finding fraud and abuse and sharing it with states] in a rigorous way.” 

And a 2020 GAO watchdog report found that at least 63% of MAOs encounter data is missing national provider identifiers, data essential to tracking provider ordering, prescribing and billing habits. As the report states, “Both CMS and OIG rely on NPIs for ordering providers to conduct oversight and pursue fraud investigations.” 

As stewards of taxpayer dollars, MCOs and MAOs have a duty to thoroughly combat fraud, waste and abuse. To more effectively manage FWA in your organization, you need to be sure your solution has the following three key components:  

1. Technology 

According to CMS, Medicare improper payment rates have been steadily decreasing while Medicaid’s have been rising. The robust fraud initiatives in the Medicare program have been given the credit for the progress there, and their strategy was recently updated with the aim of further improving the effectiveness through 5 pillars:

  1. Stopping bad actors
  2. Preventing fraud
  3. Mitigating emerging programmatic risks 
  4. Reducing provider burden
  5. Leveraging new technology 

Steps to ensure proper payments have been taken in the Medicaid program as well. In 2018, under the third pillar of its reform initiative – integrity and accountability – CMS announced audits of state programs to review Medicaid enrollee eligibility as well as if programs are correctly reporting medical loss ratios. It also promised to leverage increased data sharing and analytics and step up provider education of proper billing practices. In 2019, it released a new rule intended to prevent known fraudulent providers from billing government insurer programs. 

The continued focus of CMS on eliminating Medicaid and Medicare fraud, waste and abuse means that health plans need to properly utilize technology to gain transparency into their process. Health plans and managed care organizations have to connect large volumes of data in order to comply with fraud, waste and abuse regulations. Advanced technolog– especially a solution that leverages applications of A.I. like deep learning – can integrate and process large amounts of data and to identify anomalies and patterns more effectively than people can do alone.

Technology-enabled fraud, waste and abuse solutions can quickly turn things around for MCOs – especially if they are plugged into a larger, more integrative payment integrity system. Documentation, risk identification, referrals, audit preparation and reporting are all capabilities that a robust fraud, waste and abuse technology solution can provide to MCOs and health plans.

 2. Clinical Audits 

The second element a preventive fraud, waste and abuse program needs to have is the ability to perform clinical audits. This gives MCOs and other payers and health plans the ability to review claims that have been flagged as potential fraud, waste or abuse cases. Clinical audits determine if diagnoses, prescriptions, encounters, procedures, and more are worthy of further investigation or not. An internal audit program is beneficial to a health plan, as it can often be used to prevent improper payments from occurring in the first place. 

While retrospective provider audits can unnecessarily stress the payer-provider relationship, that doesn’t have to be the case. By connecting real-time data between providers and payers, streamlining the medical records request process, seamlessly coordinating with vendors to prevent overlap, and transitioning more efforts prepay – all supported by Pareo – you can work to mitigate provider abrasion while satisfying compliance requirements.

Notably, the ability to analyze claims data and use predictive modeling allows a health payer, plan or MCO to effectively safeguard against fraud, waste and abuse. Tech-enabled clinical audits, like those performed within Pareo by a services vendor, can either complement or supplement the internal efforts of a health payer as well as those performed by Recovery Audit Contractors (RAC) for outlier billers. However, RAC audits have reduced significantly in recent years as payers move away from fee-for-service arrangements.

 3. Investigative Capability 

Increasingly, health plans, payers and MCOs should arm their FWA programs with a strong investigative arm in order to protect against non-compliance. If fraud is suspected, investigative capabilities allow direct reporting of fraud schemes to the appropriate authorities, providing evidence that supports (and protects) health payers and taxpayer funds. Should a claim be taken to court, both the evidence and a documented FWA process within a health insurance organization prove invaluable.

The amount of big data collected by healthcare organizations presents incredible opportunities to those invested in fraud, waste and abuse prevention. Governmental agencies are now using big data to investigate and prosecute FWA offenders. Mike Cohen, an operations officer with the OIG’s Office of Investigations, explains that “data…creates a pyramid effect, and we can go to the top of that pyramid.” And as fraud schemes grow increasingly sophisticated, the evidence data must evolve along with it. 

Pareo® supports investigative activities across a healthcare organization’s data ecosystem, and ClarisHealth staffs a team of expert-level investigators, a benefit which also supports cyber threat intelligence efforts. As with clinical auditing, the investigative component of a fraud, waste and abuse program can be  partially or completely outsourced to ClarisHealth.

Request a Fraud, Waste and Abuse Presentation 

Does your organization have what it takes to effectively prevent Medicaid and Medicare fraud, waste and abuse? Find out by requesting an FWA presentation from ClarisHealth, where a member of our team will discuss your specific needs.

Learn more about the ClarisHealth 360-degree solution for payment integrity and FWA, Pareo Fraud: Case Management and Detection powered by A.I. here.

NOW'S THE TIME FOR TOTAL PAYMENT INTEGRITY

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.”  

NOW'S THE TIME FOR TOTAL PAYMENT INTEGRITY

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

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.”

(source)
U

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.

NOW'S THE TIME FOR TOTAL PAYMENT INTEGRITY

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

 FACT: Elimination of private insurance is highly unlikely.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Lack of Documentation is a $23 Billion Overpayment Problem for Medicare

Lack of Documentation is a $23 Billion Overpayment Problem for Medicare

Medicare overpayment is a massive problem, and lack of documentation is a significant contributor.

When we see errors adding up to billions of dollars in improper payments, we pay attention. As payment integrity technology experts and also healthcare consumers we take notice when Medicare fee-for-service programs get slammed for $23 billion in improper payments due to documentation errors. More jaw dropping? Poor documentation processes cause 64% of improper payments in Medicare.

Let’s take a deeper look at how the problem of insufficient documentation became so huge and what you can reasonably do to address documentation errors at your health plan.We have considerable experience on the provider side of healthcare, and our interest in payment integrity is hyper-focused on automating some of the documentation processes required by the federal government.

Just How Big of a Problem are Medicare Overpayments?

When we discuss Medicare overpayment issues, it’s usually a million+ or billion-dollar problem. Recent headlines point to this fact:

CMS may overpay Medicare Advantage plans by billions, study finds

SUTTER HEALTH, AFFILIATES TO PAY BACK $30M FOR MEDICARE ADVANTAGE OVERPAYMENTS

$50 billion in Medicare waste? Yes, that’s how much in ‘improper payments’ are made per year

We’ve spent a considerable amount of time on our blog discussing fraud, waste and abuse and the role these elements play in improper payments. The problem is complex, and the solutions have to be agile and at-the-ready in order to be effective. According to Seto Bagdoyan, a director of audit services at the Government Accountability Office (GAO), of the “billion dollar a week” waste figures cited for 2017, $45 billion can be attributed to overpayments.

Some experts counter that the way HHS calculates waste is “weak,” and Medicare may actually have a larger problem than the already outsized figures making headlines. It’s hard to fathom the depths that Medicare waste truly runs, but being the problem solvers we are, we urge you to look at one sizable chunk of the problem: Improper Documentation.

u

What is “Poor Documentation” and What Causes It?

If you can’t easily see the patient’s medical “story,” you’re likely looking at insufficient documentation.

Poor documentation has devastating impacts on patient care and is also a large driver of the improper payment problem. Health leaders attribute poor documentation problems to:

  • Busy Providers
  • Lack of specificity
  • Need for documentation education
  • Diluted content from “copy and paste” methodologies

CMS indicates that documentation needs to occur during or quickly following a patient visit and should follow the principles outlined in this document (which includes stating the rationale behind ancillary services or documenting in a way that makes the reason easily inferred).

 

“In fiscal year 2017, insufficient documentation comprised the majority of estimated FFS improper payments in Medicare and Medicaid, with 64 percent of Medicare and 57 percent of Medicaid improper payments due to insufficient documentation.” (source)

 

Most Overpayments Stem from Documentation Errors

Recently, the GAO reported in detail that overpayments in Medicare and Medicaid are mostly due to “insufficient documentation.” GAO figures the amount to be $23.2 billion for Medicare alone and $4.3 billion for Medicaid. CERT review criteria changed in 2009 and was attributed as a primary cause for discrepancies between FFS programs; Medicaid’s rate of insufficient documentation is only 1.3% while Medicare is over 6% on all claims.

The way medical reviews have been conducted is now being questioned, with the GAO citing the following four areas of difference:

  1. Face-to-face examinations
  2. Prior authorizations
  3. Signature requirements
  4. Documentation from referring physicians for referred services

The truth is, poor documentation is a problem we saw coming. We know that providers are busy, that their primary focus is serving patient needs, and that most EHR “solutions” are just more manual obligations for busy medical staff. Across the board, the ability to connect data between disparate systems is one that our industry has struggled to solve. That’s what makes Pareo® so unique. And with administrative complexity only growing, we’ve worked up a solution.

Pareo® Clinical: Our Hyper-focused Solution

Pareo® Clinical is the answer to streamlined workflows, a full document repository to support the audit findings, and the ability to develop more robust analytics that can be implemented earlier in your processes to catch documentation deficiencies before the payment goes out the door.

And if under-documentation is an ongoing problem with certain providers, Pareo® Provider can open up the lines of communication between payer and provider and offer education to mitigate that issue in the future. Providers want to submit clean claims, after all.

Learn More

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

More from Our Blog:

You Don’t Need Rules to Mitigate Healthcare FWA

You Don’t Need Rules to Mitigate Healthcare FWA

Health plan SIUs find deep learning models for fraud detection provide advantages over rules-based tools.   The onset of the novel coronavirus pandemic highlighted a glaring weakness in rules-based FWA systems: the need to develop rules well ahead of their actual use...