Listen to this conversation about building the right team and technology to help health plans tackle their entire payment integrity continuum.
ClarisHealth CEO Jeff McNeese sat down with Steve Krupa, CEO of Healthedge and contributing host at Healthegy, for the latest episode of the Breaking Health podcast. These two know payment integrity, and their conversation offers distinct value for health plans looking to make progress on payment accuracy goals.
The 30-minute episode answers:
Why is ensuring claims payment accuracy so complex?
How does ClarisHealth think about helping solve healthcare’s biggest challenges?
Why are health plan leaders forced to settle for solutions that don’t match their vision?
What is the best competitive advantage any health plan can acquire to innovate?
How can root cause analysis of claims leakage help health plans focus on their cost containment strengths?
How can health plans use third-party services suppliers to best mutual advantage?
What is the best way to adopt advanced technology to ensure high ROI?
NASHVILLE, TENN. (PRWEB) SEPTEMBER 09, 2020 - - ClarisHealth, the company transforming health plan operations with its comprehensive payment integrity technology platform Pareo®, launched today an artificial intelligence-based (A.I.) solution for healthcare fraud detection. Pareo Fraud Detection works seamlessly with Pareo Fraud Case Management for an integrated, 360-degree approach to mitigating fraud, waste and abuse (FWA).
According to Mark Isbitts, Vice President of Program Integrity for ClarisHealth, who led the project, Pareo Fraud Detection provides significant advantages over conventional tools that have been in use for decades. This traditional approach involves sifting through massive amounts of data and defining thousands of rules to detect fraud, which limits its scope of effectiveness.
"Currently, the SIU deals with overwhelming numbers of false positives and manual processes and still may miss some aspects of fraudulent activity and new emerging criminal schemes,” says Isbitts. “Pareo Fraud Detection is based on our proven payment integrity technology platform and features a transparent and efficient user interface that provides a view of why a provider is marked as fraud and enables investigators to visualize different patterns and scenarios in just a few clicks – without inputting multiple rules. ”
Pareo Fraud Detection models were developed in partnership with data science experts from the College of Business Administration at the University of Illinois-Chicago (UIC). Kyle Cheek, PhD., the Director of the Center for Applied Analytics and a clinical associate professor of Information and Decision Sciences at the university, has worked in various payer fraud organizations. He helped ensure the solution escaped a fundamental drawback of A.I.: lack of explainability.
“An A.I.-based technique is not usually transparent about how it generates its outputs and is often referred to as the ‘black box,’” says Cheek. “However, Pareo Fraud Detection harnesses the power of deep learning applications of A.I. informed by domain expertise so the SIU will get information on which providers to investigate first, why a provider is suspicious, and how valuable the investigation can be – in real-time, efficiently, and with limited manual efforts.”
The release of Pareo Fraud Detection continues the ClarisHealth strategic direction of expanding the native functionality of the Pareo platform to maximize health plan cost avoidance and recoveries at the most optimized cost. According to ClarisHealth CEO Jeff McNeese, this approach is termed Total Payment Integrity™ and it transforms engagement with internal and external stakeholders.
“Just like there had been little innovation in payment integrity before Pareo, the same has been true for FWA solutions,” says McNeese. “Being able to solve payment integrity and FWA challenges end-to-end – from prepay to post-pay – on a single platform fulfills the Total Payment Integrity promise of Pareo.”
ClarisHealth is the answer to the health plan industry’s siloed solutions and traditional models for identification and overpayment recovery services. ClarisHealth provides health plans and payers with total visibility into payment integrity operations through its proprietary advanced cost containment technology platform Pareo®. Pareo enables health plans to maximize avoidance and recoveries at the most optimized cost for a 10x return on their software investment. For more information please visit https://www.clarishealth.com.
ClarisHealth Ranks No. 8 Among Tennessee Software Companies on the 2020 Inc. 5000
NEW YORK and NASHVILLE, Tenn., August 13, 2020 – Inc. magazine today revealed that ClarisHealth is No. 8 among Tennessee software companies on its annual Inc. 5000 list, the most prestigious ranking of the nation’s fastest-growing private companies. The list represents a unique look at the most successful companies within the American economy’s most dynamic segment—its independent small businesses. Intuit, Zappos, Under Armour, Microsoft, Patagonia, and many other well-known names gained their first national exposure as honorees on the Inc. 5000.
“The incredible growth of ClarisHealth has only begun, as represented by our first appearance on this list,” says Jeff McNeese, CEO of ClarisHealth. “The team’s laser focus on transforming engagement in healthcare and their commitment to our Got Your Back culture makes this accomplishment possible.
Not only have the companies on the 2020 Inc. 5000 been very competitive within their markets, but the list as a whole shows staggering growth compared with prior lists as well. The 2020 Inc. 5000 achieved an incredible three-year average growth of over 500 percent, and a median rate of 165 percent. The Inc. 5000’s aggregate revenue was $209 billion in 2019, accounting for over 1 million jobs over the past three years.
Complete results of the Inc. 5000, including company profiles and an interactive database that can be sorted by industry, region, and other criteria, can be found at www.inc.com/inc5000. The top 500 companies are also being featured in the September issue of Inc., available on newsstands August 12.
“The companies on this year’s Inc. 5000 come from nearly every realm of business,” says Inc. editor-in-chief Scott Omelianuk. “From health and software to media and hospitality, the 2020 list proves that no matter the sector, incredible growth is based on the foundations of tenacity and opportunism.”
The annual Inc. 5000 event honoring the companies on the list will be held virtually from October 23 to 27, 2020. As always, speakers will include some of the greatest innovators and business leaders of our generation.
ClarisHealth is the answer to the health plan industry’s siloed solutions and traditional models for identification and overpayment recovery services. ClarisHealth provides health plans and payers with total visibility into payment integrity operations through its proprietary advanced cost containment technology platform Pareo®. Pareo enables health plans to maximize avoidance and recoveries at the most optimized cost for a 10x return on their software investment. For more information, please visit www.clarishealth.com.
More about Inc. And Inc. 5000
The 2020 Inc. 5000 is ranked according to percentage revenue growth when comparing 2016 and 2019. To qualify, companies must have been founded and generating revenue by March 31, 2016. They had to be U.S.-based, privately held, for profit, and independent—not subsidiaries or divisions of other companies—as of December 31, 2019. (Since then, a number of companies on the list have gone public or been acquired.) The minimum revenue required for 2016 is $100,000; the minimum for 2019 is $2 million. As always, Inc. reserves the right to decline applicants for subjective reasons. Companies on the Inc. 500 are featured in Inc.’s September issue. They represent the top tier of the Inc. 5000, which can be found at http://www.inc.com/inc5000.
About Inc. Media
The world’s most trusted business-media brand, Inc. offers entrepreneurs the knowledge, tools, connections, and community to build great companies. Its award-winning multiplatform content reaches more than 50 million people each month across a variety of channels including websites, newsletters, social media, podcasts, and print. Its prestigious Inc. 5000 list, produced every year since 1982, analyzes company data to recognize the fastest-growing privately held businesses in the United States. The global recognition that comes with inclusion in the 5000 gives the founders of the best businesses an opportunity to engage with an exclusive community of their peers, and the credibility that helps them drive sales and recruit talent. The associated Inc. 5000 Conference is part of a highly acclaimed portfolio of bespoke events produced by Inc. For more information, visit www.inc.com. For more information on the Inc. 5000 Conference, visit http://conference.inc.com/.
Now that the rules promoting interoperability have been finalized, here’s how payers can prepare to take full advantage of the freer exchange of healthcare data.
On March 9, 2020, the two separate rules issued by CMS and ONC against Information Blocking became final. The administration lauded the release by touting the consumer benefits: “Americans will now have electronic access to their health information on their smartphone if they choose.” While that impact is undeniable, health plans, on the other hand, likely have a more pressing near-term question, “Now what?”
As we wrote in our last article on this topic, just over 40% of health plans report progress on interoperability, which leaves some work to do. One industry leader echoes concerns about the complexity of complying with the rules in a recent comment. "In the near term, information is going to be messy and incomprehensible, for the most part, but over the long term, it creates a dynamic where access is the first step to be able to do something important with the data."
With that very astute observation in mind, we have outlined a 4-step plan for health plans to move forward during the “messy” beginning and make progress toward the actionable data goals of interoperability.
1. Get important stakeholders on board
If you haven’t done so already, your first step should be to form a steering committee made up of knowledgeable contacts from affected areas of the health plan: privacy and security officers, compliance, IT, finance, member support. Their input will be invaluable as you assess your current state of readiness.
The team can collectively identify:
Where all electronic health information is held within the organization. List all systems and the type of information each contains. Go deep and wide to corral everything that could possibly fall under this broad definition, as well as to set yourself up beyond compliance toward strategic advantage.
Policies and procedures that address information sharing. Includes HIPAA compliance, IT policies, and internal agreements covering confidential and proprietary information.
What workflows have been implemented to accommodate EHI requests. Includes how they are processed, who reviews, turnaround times, security tests, and any documentation around these processes.
2. Highlight barriers to compliance
While your team assesses the current state of affairs, they are bound to find roadblocks keeping your health plan from sending and receiving EHI in a timely manner. The look-back period for consumer inquiries is 5 years, including for members who have changed plans. Can you aggregate and return information to members within 1 to 2 days?
Technical challenges are the most likely barriers that health plans will have to grapple with. Of note, the myriad of disconnected systems that house EHI. Consider initiating a trial request to send and receive information on a tight turnaround and evaluate your success along the way.
You’ll want to look for potential blind spots now, before it’s an emergent situation. For instance, if you’re able to accommodate the request, but in doing so, it sidelines key personnel from their primary work functions. Or, maybe the process falls through a communication gap -- either internal or with a third-party. Perhaps it’s impractical to retrieve information from systems at all. Document any obstacles.
3. Make a plan
Your audit to reveal the current state of your organization’s ability to share EHI likely highlighted some known quantities as well as a few surprises. The next step is to make a plan to overcome those gaps in communication and technical requirements.
Communication. Initiate new internal processes, and amend contractual agreements with third-party vendors and business associates and providers, if needed. The EHI ecosystem is vast, and eliminating information blocking will require these relationships to evolve accordingly.
Technology. The ONC rule provides more specifications on the technical side. The finalization of these rules could finally urge all healthcare stakeholders to settle upon the normative version of FHIR (v. 4) to standardize APIs. We have written before how APIs promise to help connect our disconnected systemsand promote information sharing. A great deal of patient healthcare claims information has already been made available through open APIs, with more planned; it’s only a matter of being able to receive that information. Because your adjudication and processing systems likely use the EDI X12 standard, you may have to support both for a while.
In addition, new algorithms, analytic capabilities, blockchain and machine learning (ML) capabilities can help parse unstructured data, deal with increased data volume, and otherwise unlock the value of the data.
4. Communicate about your progress
This rule demands transparency, so start by communicating openlyabout your progress with internal stakeholders as well as providers, service suppliers and technology vendors. Opening the lines of communication is essential to breaking down the work silos that hinder interoperability.
Also, consider getting involved in the FHIR community, by piloting and testing at connectathons. The process may not be as onerous as you imagine; providers and health plans alike have been pleasantly surprised by 90-day infrastructure compliance timelines. Communicating with the governing body for future-ready standards and exchanging best practices with like-minded stakeholders promises to move the entire industry forward.
Bottom Line: The Carrot Before the Stick
If your health plan maintains their focus on the benefits to members, progress towards your strategic goals are sure to follow. According to Don Rucker, M.D., national coordinator for health information technology, “A core part of the rule is patients’ control of their electronic health information which will drive a growing patient-facing healthcare IT economy, and allow apps to provide patient-specific price and product transparency.”
While penalties for information blocking have yet to kick in (the stick), the strategic advantage carrot is particularly enticing. The U.S. healthcare system has been “promoting interoperability” for years, and the finalization of these rules finally codifies the standards that enable that goal. Now is your opportunity to fully embrace advanced technology and the freer exchange of health information to enhance care coordination, lower costs and improve outcomes.
NOW'S THE TIME FOR TOTAL PAYMENT INTEGRITY
SeetheClarisHealth360-degree solution for total payment integrityin action:
Doug Ghertner and George Lazenby, IV, add significant expertise to the healthcare payer technology company’s board of directors
NASHVILLE, Tenn., Jan. 30, 2020 – ClarisHealth, the company transforming health plan operations with its comprehensive payment integrity technology platform Pareo®, today announced two additions to its Board of Directors. Doug Ghertner and George Lazenby, IV, both healthcare technology veterans, were approved unanimously.
Ghertner currently serves as the CEO of IVX Health, a national provider of infusion and injection therapy for individuals with chronic disease. He brings more than 20 years of healthcare experience to the Board, including senior leadership positions at CVS Health, Change Healthcare and Emdeon. As CEO of Change Healthcare, Ghertner oversaw its acquisition by Emdeon in 2014 and assumed the role of Executive Vice President and Chief Sales Officer through 2017.
Lazenby co-founded and serves as CEO of OrderInsite, a provider of tools and advanced analytics to manage and control prescription drug inventory. He has more than 20 years of healthcare IT experience, including CEO of Emdeon, the nation’s largest health information network. Lazenby led Emdeon through a successful IPO in 2009 and sale in 2011. He also serves as a board member for Concert Genetics, ProxsysRx and CarePayment.
In just three years, ClarisHealth has grown Pareo to tens of millions of health plan members supported by the platform today through leading national and regional payer partnerships. Given the company’s strong market momentum, leadership expects to exceed 100 million members supported by Pareo over the next 18 months.
“ClarisHealth has experienced rapid adoption of our leading platform Pareo®, and it is important for us to routinely tap into thought leaders who will help us navigate the opportunities of a fast-growing business. Doug and George each bring a unique and incredibly valuable perspective to our Board of Directors, ” said Jeff McNeese, CEO of ClarisHealth. “We credit the leadership of our Board with the strategic success of ClarisHealth and look forward to seeing that grow in the coming years under the guidance of proven leaders in our industry.”
Mr. Ghertner and Mr. Lazenby join co-founders Darby Brown and Jim Sohr, who formed the company in 2013 to bring unique technology-enabled solutions to the payment integrity industry. ClarisHealth works with leading health plans across the country to drive significantly higher recovery performance while maximizing productivity.
ClarisHealth is the answer to the health plan industry’s siloed solutions and traditional models for identification and overpayment recovery services. ClarisHealth provides health plans and payers with total visibility into payment integrity operations through its proprietary advanced cost containment technology platform Pareo®. Pareo® enables health plans to maximize avoidance and recoveries at the most optimized cost for a 10x return on their software investment. For more information please visit clarishealth.com.
Industry veteran will extend ClarisHealth’s strategic direction in accelerating adoption of market-leading technology solutions for health plans.
NASHVILLE, Tenn., Jan. 20, 2020 – ClarisHealth, the company transforming health plan operations with its comprehensive payment integrity technology platform Pareo®, hired Mark Lavallee as Chief Growth Officer. In this newly created role, Lavallee will lead the sales team in expanding ClarisHealth’s presence in the health plan market.
Lavallee has over 30 years of sales and marketing experience, including 15 years in healthcare payment integrity and data analytics. He has led the strategic sales efforts for some of the leading providers of technology and services for health plans, growing those companies from early stage to market leaders.
Lavallee most recently served as Vice President and Head of Key Accounts at EXL, Senior Vice President of Sales at SCIO Health Analytics before their acquisition by EXL, and the Chief Marketing Officer at National Audit up until their acquisition by SCIO Health Analytics.
“We are thrilled to add Mark to our growing executive team,” said Jeff McNeese, CEO of ClarisHealth. “His industry expertise and track record with accelerating growth at early-stage companies promises to take our sales organization to the next level.”
“What ClarisHealth has developed is the most innovative solution I’ve seen in my 15 years in healthcare payment integrity. Pareo leverages technology to maximize medical savings and reduce administrative burden while introducing unprecedented transparency,” says Lavallee. “I very much look forward to helping ClarisHealth lead health plans forward in their journey towards transforming their payment integrity and fraud, waste and abuse processes.”
Lavallee began his career in sales and marketing in 1986 when he joined General Motors Corporation as a cooperative education student, and since then, he has held numerous senior sales and marketing positions within Fortune 200 and other large organizations such as American Honda Motor Company and Automatic Data Processing (ADP). He received a Bachelor’s Degree at GMI Engineering & Management, now called Kettering University, in Flint, Mich. He lives in the greater Miami area with his family.
ClarisHealth is the answer to the health plan industry’s siloed solutions and traditional models for identification and overpayment recovery services. ClarisHealth provides health plans and payers with total visibility into payment integrity operations through its proprietary advanced cost containment technology platform Pareo®. Pareo®enables health plans to maximize avoidance and recoveries at the most optimized cost for a 10x return on their software investment. For more information please visit clarishealth.com.