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)
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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.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

 FACT: Elimination of private insurance is highly unlikely.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Just How Big of a Problem are Medicare Overpayments?

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

CMS may overpay Medicare Advantage plans by billions, study finds

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

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

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

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

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What is “Poor Documentation” and What Causes It?

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

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

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

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

 

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

 

Most Overpayments Stem from Documentation Errors

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

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

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

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

Pareo® Clinical: Our Hyper-focused Solution

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

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

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

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Forget the Buzzwords. Lack of progress now doesn’t mean you’ll never catch up.

Forget the Buzzwords. Lack of progress now doesn’t mean you’ll never catch up.

3 practical steps you can take today if your health plan is feeling left behind on advanced payment integrity technology

A few weeks ago, a blog reader approached me about a recent article I wrote titled “Does Your Health Plan Even A.I.?” The reader, who also happens to be a director at a smaller health plan, said something to me that really struck a chord. She said, “Forget A.I. We’re still struggling to process all the requests that come in daily. There’s no way we can think about advanced technology like that right now.” And you know what? This reader isn’t alone. Her health plan isn’t the only one that, rather than facing a fear of missing out (FOMO, as my 8 year old tells me) they are fearful of falling behind.

Pareo® isn’t just for health plans who feel they are “ready” to be forward thinking. It was created to help you innovate, wherever you are in the payment integrity process. Imagine what plagues your PI processes the most, and that’s where we start. Just because something is labeled “advanced technology” or another industry buzzword doesn’t mean it is more difficult for you to use or implement.

You don’t have to be “caught up” when you seek out an advanced technology solution. Rather, you just have to know where to begin.

What’s really stopping you?

I’m going to detour for a moment, so stick with me. Have you ever put something off that’s beneficial because the time wasn’t right? “Sure,” you say, “I should go get that sleep study done, BUT I’ll wait until the kids are back in school or until this big project at work clears up.”

How often does the waiting actually pay off? Do you ever realize that if you’d just gotten the sleep study when your doctor recommended it, the help would’ve come sooner? Putting things off until the “time is right” very often just means that you have to wait longer for help to come.

We speak with health plans who have these same feelings, applied to payment integrity. They tell us “We’re too busy right now” or “We’re too behind” or even “We don’t need help.” And when it comes to advanced technology? “Sounds nice, but we’re struggling to use the technology we have,” they’ll say. But they also tell us that something isn’t working. It makes sense. Professionals all over feel like they’re falling behind, including athletes, marketers, and medical care providers.

 

“In what’s rapidly becoming a mobile-first business world, all manner of industries are being ‘shaken up’ by digital innovation.”

Bryan Kirschner, director of the Apigee Institute

 

Start Gaining Traction

All these buzzwords are flying around and while they’re exciting, they’re also a bit nebulous. This feels especially true for health plans that are facing change on multiple fronts: reform, technology, workforce shortages and other external stressors. It’s understandable that when we throw around terms like AI, ML, Big Data, and NLP that health plans may feel overwhelmed — the healthcare industry is in the process of being disrupted.

Let’s look at three things you can do right now to start gaining traction in your payment integrity efforts:

1. Find the Best Next Step (and Take It)

The best advice on taking action when you feel overwhelmed is simply to start small. It never hurts to seek advice on this front from a trusted resource (we are always happy to help). For instance, you may benefit by performing an “audit” of your current payment integrity operations.

2. Set a Goal for Advanced Technology Integration

Now is not the time for everyone to embrace artificial intelligence, machine learning, and more — and that’s ok. But change is on the horizon, and your best bet is to set a goal to implement some form of advanced technology into your payment integrity operations. Health plans need to continue to focus on data sharing and their ability to comply with regulations requiring interoperability. Pareo®, while equipped with advanced technology, seeks to support data sharing goals at organizations through comprehensive access to information.

3. Power Through Feeling “Stuck”

When you fear you’re falling behind, there’s no need to feel discouraged. If you get stuck along the way, ask yourself if what you are experiencing is physical or psychological (called “paralysis by analysis”). In addition to structural roadblocks like lack of resources, other common barriers to advancement are rooted in emotions like fear. (Symptoms include pesky internal dialogue featuring “should have done …” and “what if …”) Stepping outside of the problem to gain insight into what’s causing your PI operations to fall short is a powerful way to power through problems. Additionally, transparency can be a key tool for health plans that feel stuck.
ClarisHealth seeks to be your partner in total payment integrity, so remember: you don’t have to go it alone. And while we do offer an advanced technology solution, we aren’t robots. We’re real people, passionate about helping your health plan find its focus, increase recoveries, and get ahead of the curve in this increasingly complex industry.

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

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Burned out and Bored? Remind Your Employees Why Payment Integrity Matters

Burned out and Bored? Remind Your Employees Why Payment Integrity Matters

Address the “why” behind payment integrity and you’ll find that health plan employees no longer feel stuck.

Most talented employees start out in their jobs with a great deal of optimism: meeting new people, learning new things, looking forward to making a positive impact. Seeking to challenge and be challenged and grow within the role and future roles. What if, instead, every day they are faced with challenges they can’t surmount by working and thinking harder? What if they are surrounded by people who, in the face of such odds, have given up on that situation ever improving?

It can be really demoralizing to feel like you’re not progressing toward your goals. At health plans, where payment integrity system processes have remained largely unchanged for 20+ years, this type of burnout and disengagement is a real risk.

 

Our ‘why’ is helping you get excited about payment integrity. Pareo® can free you to do the job you set out to do: innovating, instead of battling barrier after barrier.

 

Is Your PI Team Suffering from Burn- or Bore-Out?

We’ve all been there — frustrated by redundant processes, tired of the same ineffective workflows, or just bored because you’re doing work that is manual (when it could be automated). How does this affect payment integrity processes? Employees who suffer from burn-out or bore-out don’t have the tools or stimulation they need to contribute as much as they once did, even if they’re working in their dream career.

 

“Actively disengaged employees cost U.S. companies between $450 – $550 billion in lost productivity per year.” That’s at least $14,000 per second. (source)

 

Burn-out, or feeling disengaged from your work to the point of stagnation, differs from bore-out which refers to extreme boredom at work (a signal that an employee isn’t challenged enough). Both conditions stem from repetitive processes and are heightened when employees cannot effectively do their jobs. Overwork can further amplify employees who are feeling burned out or bored. And in the healthcare industry, where we all are asked to “do more with less” and shepherd wearisome administrative processes, chances are your PI department is burned out.

 

Discomfort is a hallmark of technology changes, but it’s also a cure for employee burn-out. Challenging what you think you know is a healthy work process.

 

Health plans should gauge employee engagement and productivity in order to determine if burn-out is occurring. Due to high costs of productivity losses and the demands of the healthcare industry, you simply cannot afford to allow burn-out and bore-out to persist. Furthermore, combating burn-out can be as simple as reminding your staff “why” what they do matters.

Modernizing payment integrity is a huge opportunity, one that Pareo® helps your team manage. Arming your payment integrity department with the reasons to move forward and the right tools is a powerful cure for burn- and bore-out.

The Why Behind Pareo — and Why It Matters

Schedule a demo or meet with us in person and it won’t take long before you notice: ClarisHealth is full of passionate people. It stands out  in an industry that seems a little “stuck.” Our company was founded after years of working in payment integrity, years that informed our belief that technology could revolutionize the industry. Inevitably, we came to the conclusion that health plans (and providers) simply cannot do what they need to in the dark.

We felt compelled to shine a light on outdated processes and transform payment integrity. The reams of data that are collected by healthcare organizations are only useful if you can, well, use them. Many of us at ClarisHealth have been right where your employees are — met with lots of demands but ill-equipped to meet them.

That’s why we understand the problems your health plan faces, and why we feel confident that we can help you solve them.

Beat Burn-out with Innovation

An innovation partner like ClarisHealth does more than just enable you to grow recoveries (though we’re pretty great at that). We view our relationships with clients as a commitment to growth and innovation. We partner with you to solve the problems that have plagued your health plan for decades. If this sounds exciting, that’s because it is. We’ve had clients say that our solution is like nothing else they’ve ever encountered before.

 

“Pareo® was unlike anything on the market. It was the only comprehensive payment integrity platform that covered all the bases. It also comes with highly valued functionality like a medical records repository and a robust analytics suite that will enable us to internalize more of our payment integrity operation.  The team at ClarisHealth has a very deep knowledge of the payment integrity market and it shows in the product they have built.”

Senior Manager of Payment Integrity, State Health Plan

 

Your PI team will be enthused to learn that a real, powerful solution — a people-centric solution — is available from ClarisHealth. Burn-out can be transformed into passion with the right tools. Our payment integrity solution offers:

 Clear processes

 Meaningful data to impact results

 Elimination of silos and other barriers that hinder progress

 

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

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

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

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

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

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

What’s at stake? Your rate of recovery.

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

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

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

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

Get the Checklist

Click to download our Payment Integrity comparison tool.

Functionality is the Top Consideration

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

1. Supplier Optimization

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

2. Audit Workflow and Analytics

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

3. Clinical Workflow and Analytics

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

4. FWA Case Management and Analytics

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

5. Reporting and Business Intelligence

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

6. Provider Engagement

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

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

Additional Payment Integrity Evaluation Areas

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

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

1. Flexibility

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

2. Value Perks

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

3. Integration and Ease of System Implementation

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

4. Data Accessibility

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

5. Working with the Vendor

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

How Does Comprehensive Payment Integrity Stack Up Against Other Solutions?

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

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

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

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

 

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