ClarisHealth on the Breaking Health Podcast

ClarisHealth on the Breaking Health Podcast

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?
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 hurdles. To 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 initiatives. Increased 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 Finance. Health 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 own. It’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.

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

6 Steps to a Successful Prepay Strategy

6 Steps to a Successful Prepay Strategy

Health plans can take control of their own prospective provider audits instead of over-relying on services vendors with the help of advanced technology and access to proven analytics. 

We’ve written before about why it’s important for health plans to start thinking about moving more of their audit activities earlier in the claims payment process. The potential for increased cost savings and reduced provider abrasion are significant drivers for every future-looking health plan to transition payment integrity efforts to a healthy mix of prepay and post-pay led by both internal and external resources. But with entrenched challenges to achieving this goal, it’s easy to understand why many health plans rely solely on third-party services suppliers for prospective provider audits – if they’re able to focus on this area at all. 

If your health plan is just starting out with this realignment, we put forward six recommendations to progressing on your prepay strategy step by step. However, payment integrity operations vary greatly in sophistication, and this plan is designed to meet you where you are. So, feel free to pursue a slightly different path from current state to full transformation. 

What are the most common prepay audits performed by payers?

  • Mismatched CPT or ICD codes 
  • Incorrect coding 
  • Lack of medical necessity 
  • Upcoding and unbundling 
  • Missing or wrong modifiers 
  • Other coverage 

1. Adopt advanced technology

Strategic directors of payment integrity understand the potential of digital transformation: a greater focus on prepay functions yields a better balance between internal and external functions and improves recovery returns. Breaking down data silos to centralize efforts is the first phase, and adopting advanced technology is key to this goal. 

Instead of multiple technology systems and manual processes that historically characterize health plan operations, you can unite disparate internal payment integrity departments and vendor information under a single technology platform. Especially if that technology supports APIs for real-time data feeds from service vendors, industry databases, provider EHRs and best-of-breed applications, which enables plans to streamline payment integrity operations and support their organization in owning prepay strategies. 

Scalable platforms like Pareo are particularly suited to this task. Because it is designed to get internal and external stakeholders on the same page, service vendors and audit staff can achieve alignment with real-time information exchange and visibility on progress. 

2. Optimize post-pay recovery efforts

While a health plan’s goal is to ultimately reduce the overall retrospective effort in favor of primarily prospective claims validation, successful post-pay recovery is the foundation. In fact, the predictive analytics that form the foundation of prepay concepts often rely on compiling historical results to improve precision. So, start by ensuring you have all areas of payment integrity covered – coordination of benefits, data mining, medical record review, contract compliance, and fraud and abuse detection – and coordinating these efforts between internal and vendor resources. 

This exercise should also help in the effort to evaluate provider claim submissions for trends to identify those providers that could benefit from additional support. Work to engage these providers with education and motivation to improve billing practices and submit clean claims that ensure prompt payment. Your providers want to get claims right the first time, too. 

If you have adopted an advanced technology platform, such as Pareo, its native functionality covers the full spectrum of payment integrity, including functionality that supports two-way communication with providers.  

3. Gain visibility on vendor successes

Because most health plan prepay strategies begin with outsourcing services to third-party payment integrity suppliers, the most successful prospective claims validation concepts may be siloed within those vendors. But the best partnerships are rooted in transparency. Maximizing the mutual value of the payer-vendor relationship starts with increasing visibility on assigned inventory, statuses and results of outsourced efforts.  

Integrative technology streamlines the vendor effort needed to receive claim files, submit audits, and get real-time feedback on denials, while allowing you to create multi-pass situations with lag times measured in hours, not days. Health plans can strategically stack and segment high-performing vendors and mutually develop goals with vendors all while tracking performance in real-time.  

Increased visibility on supplier performance and successes gives you more control over the entire payment integrity continuum and can help you improve cost-effectiveness. Over time, this data also provides insights that can ultimately inform internalization strategies.

4. Aggregate analytics from multiple sources

Once you have optimized post-pay recovery efforts and gained visibility into concepts that can perform well in a prepay environment, Pareo can enable your health plan to maintain a baseline library of concepts best suited to prospective savings. Some algorithms and data sets that support retrospective issues may be insufficient for prospective intervention, and the functionality of Pareo allows you to thoughtfully adjust as needed to accommodate thresholds better suited to the prepay environment.  

Payment integrity technology vendors may also be a source of prepay analytics, like those offered to Pareo clients. Along with concepts developed by internal data science resources and those internalized from outside experts, health plans can develop a robust concepts repository covering both complex (requiring medical record review) and non-complex (data mining) audits and route them directly to the platform for lead validation and adjudication. 

5. Configure workflows to maximize internal resources

At this point, health plans should be in a better position to assign internal resources to managing more prepayment audits. These prepay workflows will likely look different from post-pay recovery workflows, particularly in terms of timelines and provider engagement. 

While retrospective payment solutions may allow time for plan staff to review and validate findings, prepay operates on a much shorter timeline. Flexible, real-time integrations allow you to adhere to stringent SLA performance, maintain common audit and analytic experiences, and streamline disparate data sources. 

Health plans must manage the accuracy of prospective findings and should hold their team to an appeals uphold rate of 90% or greater. Automate as much as possible to reduce the risk of having to pay without review. Pareo leverages machine learning and other applications of A.I. to drive process automation and “learn” over time. 

Additionally, post-pay and prepay team coordination increases in importance. Retrospective recovery efforts will necessarily continue and may be better at spotting long-term trends. Real-time collaborative technology enables prepay operations to ingest post-pay intelligence to educate providers accordingly and adjust prospective validation processes to rapidly prevent future payment errors.

6. Engage providers in the transition

Finally, ensure the prepay program lives up to its promise of engaging providers and reducing abrasion. Proactively communicate with providers to get their buy-in on new policies. If you have already implemented Pareo to support your prepay strategy, leverage the integrated provider communication tool that aligns with your prepay workflow to deliver explanations of payments and denials and supports provider inquiries and appeals. Combined with dashboards that display billing patterns and other relevant analytics, this framework opens new avenues for extending the provider relationship. 

Pareo Helps You Take Control of Your Prepay Strategy 

Pareo empowers health plans to address all lines of business, prepay and post-pay, with solutions in place to continuously evaluate and move post-pay identifications internal and ultimately to avoidance. It is the industry’s only health plan-controlled payment integrity platform that allows you to shape your own strategy and have the advantage of the best technology, best analytics, and integration of all disparate areas – without relying on services vendors.  

Because of this 360-degree approach to payment integrity, health plans can easily transition post-pay analytics to the prepay environment. And, with the ability to track estimated avoidance compared to actual payments and how retrospective-to-prospective analytics reduce leakage post-pay, health plans can prove the ROI of this effort. It’s not unusual for health plans using Pareo to cost avoid in excess of 30% of all plan savings.   


See the ClarisHealth 360-degree solution for total payment integrity in action:

5 Reasons for Health Plans to Choose a Scalable Payment Integrity Technology Platform

5 Reasons for Health Plans to Choose a Scalable Payment Integrity Technology Platform

Are you using an assortment of software tools to do work better suited to a platform? You might be missing out. 

When your health plan starts looking to upgrade your payment integrity and fraud management processes with technology, what do you turn to? A tool or a platform? It’s likely not an either/or decision. Situations where only a highly specialized, best-in-breed tool will do the job are myriad. But how can you ensure your organization doesn’t deploy dozens of disconnected tools when a scalable payment integrity platform that drives your health plan’s technology ecosystem is the ultimate goal?

Defining Terms

With technology, you have options when it comes to providing solutions to your challenges. Let’s level set on some definitions of two different approaches to technology solutions.

Tool: a standalone piece of software designed to perform a single specific function or a small set of functions. It is often disconnected from other systems and processes and serves one purpose. Sometimes referred to as an “application” or “product.”

Platform: a major piece of software, as an operating system or environment, under which various smaller application programs, processes or technologies can be designed to run. Can be architected as a set of interconnected tools running inside one digital framework and user experience. Typically modular and extensible by design. A platform can be delivered as an integrated solution stack or service.

Both tools and platforms can be extremely useful. But when using them at a complex health plan organization, their limitations and potential become clear. 

Specialized Tools for Specific Needs 

It’s easy to understand the appeal of legacy standalone products, popular apps and best-in-breed tools. Think about the utility of your reliable and familiar claims editor, the specialized nature of a member engagement chatbot, or the competitive advantage provided by a set of algorithms powered by machine learning. And because these tools are often specific to a discrete function of the business, the affected departments often have the autonomy to choose, purchase and implement products on their own. 

Beware complexity

As a result of this low-threshold acquisition process, a mid-size company, on average, uses over 150 software products. And, as this number increases, so does complexity. Not only are there increased security risks and billing owners but also necessary app connections – averaging over 5,000 connections for those 150 pieces of software. Most of these tools lose their usefulness if only one user can access them, or if they’re separated from larger processes and platforms, which necessitate these connections.  

 For example, what good is that member chatbot if it doesn’t seamlessly integrate with the CRM? How efficient is that front-end claims editor if it’s disconnected from auditor prepay and recovery efforts, which are also separate from provider engagement processes? 

 It’s all too easy to find a special tool that solves the problem of the day or translates a manual process into a digital one. But,  understanding that your health plan’s challenges and goals change at an increasingly rapid pace in today’s modern world, it pays to consider flexible technology frameworks that mitigate predictably fragmented processes. 

5 Reasons to Choose a Payment Integrity Platform

With the awareness that stakeholders and processes across the health plan are increasingly interconnected, and that the pace of change is accelerating, adopting technology with flexibility and data visibility in mind is a smart move. For health plans we speak with, that leverage is exactly what the platform approach to technology adoption provides. 

With cost containment efforts driving a significant portion of operational strategy, here are 5 reasons for health plans to choose a payment integrity platform: 


1. Collaboration

As the fulcrum of the healthcare industry, health plan processes involve many stakeholders. Payment integrity efforts alone require third-party services suppliers, audit staff, the SIU and providers all to communicate at various points of the process. The tendency is to seek out collaboration or workflow tools to solve for this need – even though the key information that needs to be communicated exists outside of these tools. 

Fortunately, most platform solutions incorporate communication capabilities in addition to shared access to essential information, which allows multiple audiences to literally be on the same page. In addition, allowing every stakeholder to stay on-platform to perform their tasks creates efficiencies and stronger user habits. 

2. Seamless integration

No matter how comprehensive the functionality native to the technology platform is, outside tools – and even other platforms – will continue to be used throughout the organization. IT teams already have too many tedious integrations to manage: legacy solutions, specialized databases, cloud apps from various software vendors. But platforms turn projects that would usually require dozens of integrations into straightforward one-time connections. 

Integrating accounting platforms, CRMs, service vendor systems, provider systems, claims editors and more with a payment integrity platform provides unique synergies without overtaxing IT. Most are easily accomplished with low-code tools or simple API connections. This integration standard enables real-time data flow (unlike batch FTP) and can help health plans build a technology ecosystem that works toward healthcare data interoperability, which is mandated to be in effect for health plans by January 2021. 


3. Detailed insights and analytics

Because health plans tend to use various disconnected pieces of technology, the associated data tends to stay locked in their respective silos – along with valuable insights the data provides. But gone are the days of matching business goals to queries on last month’s or last quarter’s information. With increasing demands from internal and external forces to tap into the value of enterprise data, health plans are answering the call with the help of integrative platforms. 

Payers can increase their data management and availability capabilities substantially when most of their PI work takes place on-platform. This improvement is especially true with cloud-based platforms. Particularly when coupled with data visualization capabilities, platforms enable a strategic shift in data ownership from a centralized IT function to business groups, giving more users the power to answer any question, with any data, in real time. 


4. Configurability

Health plans tend to have unique processes and needs – even compared to other health plans – that require technology to be flexible to accommodate those differences. For most software tools, that requires custom development, which is either impossible (due to cost) or impractical (due to time). This limitation has led many a health plan down the path of building their own technology solutions with mixed results, which can include the risk of not being able to maintain a self-built tool over time. 

A hallmark of platforms, on the other hand, is configurability, which offers health plans an ideal blend of control and freedom. Solutions like Pareo, for instance, allow health plans to configure fields and workflows and user access to their specific situation, acquire additional functionality as needed, and seamlessly integrate other chosen platforms and tools to their benefit. All without substantially increasing internal IT lift by taking on software development, maintenance and security that splits focus from core operations. 

5. Scalability

The ability to collaborate and communicate with various stakeholders, seamlessly integrate with relevant technologies, derive actionable data insights, and configure your technology ecosystem determines whether your health plan can be flexible and agile. All of these platform benefits add up to a significant competitive advantage for health plans: scalability. 

Platforms support your goals to grow faster and innovate without worrying if your infrastructure and budget can accommodate accelerated plans. So, when you identify opportunities to extend product lines, boost customer service, increase operational efficiency and more that can substantially impact value, you are better poised to act on it.  

Pareo Goes Beyond a Tool 

The most successful technology strategies embrace the rapid pace of change. By taking a collaborative approach that acknowledges the interconnectedness of stakeholders and processes, health plans are much more likely to adopt a technology platform that accommodates varying needs and goals now and into the future. 

Health plans can certainly use Pareo for its discrete functionality – to manage vendors, optimize workflows, conduct data mining and complex clinical audits, engage with providers, coordinate benefits, move more efforts prepay, detect and manage fraud, and use data more strategically. But its potential to transform payment integrity operations comes to fruition when health plans leverage it as an integrative platform.

Pareo works best as the central hub for your health plan, connecting data points across your health information technology ecosystem in a way that allows you to maximize revenues, create efficiencies, achieve interoperability, and effectively manage your cost containment and fraud mitigation goals. 


See the ClarisHealth 360-degree solution for total payment integrity in action:

4 Payer Responses to Primary Care Challenges

4 Payer Responses to Primary Care Challenges

Primary care providers are the foundation of the healthcare system. With the pandemic putting its future at risk, health plans can take 4 steps to address this challenge.

It’s been said that the coronavirus pandemic hasn’t created any new problems; it’s just escalated existing ones. This maxim seems especially true for primary care providers. Primary care practices have really struggled during the pandemic – at a time when their role has never been more important. Patient volumes are down by more than half, which makes it difficult for them to stay afloat in largely fee-for-service arrangements. But even under ordinary circumstances, independent practices tend to operate at an unsustainable net loss of 20 to 30 percent a year.

Primary care providers are the keyholders for our healthcare goals: improving the health of populations, enhancing the experience of care for individuals, increasing health equity and reducing the cost of healthcare. How can payers support primary care in a way that helps improve the clinician experience so they can better fulfill their role’s potential? Let’s explore the landscape around primary care, including how it has been impacted by COVID-19, how consolidation and other factors are affecting its future, and steps health plans are taking.

Role of Primary Care

Even before the novel coronavirus, Americans in an increasing number of “provider deserts” suffered from lack of reliable access to care. As a result, they experience some of the worst issues in our healthcare system: poor healthcare outcomes and increased healthcare costs due to complex conditions exacerbated by lack of management and overuse of emergency rooms. These vulnerable populations are more likely to experience adverse effects of COVID-19, and the difference comes down to primary care.

A 2019 report found that Americans with dedicated primary care received significantly more “high-value” services, such as recommended cancer screenings, diagnostic and preventive testing, diabetes care and counseling. Those with primary care also reported better healthcare access and experience, compared to those without. These results are intuitive, but their significance can’t be overstated.

A primary care provider is often termed the “quarterback” of the healthcare system. It’s usually the longest-term relationship a patient has and, especially in the current environment where interoperability is lacking, primary care often has the most comprehensive health information available. They know the patient health history and social determinants of health, and they understand how the healthcare system operates.

Conversely, a person without a primary care provider – due to poor proximity, healthcare coverage, schedule availability, or a combination of these factors – may have access to a specialist or two, but they are likely largely relying on a cobbled together arrangement of emergency care and walk-in urgent care. None of which is designed for whole-person care and can lead to complicating events like dangerous medication interactions.

Pandemic Impact

With the patient volumes at primary care practices down significantly, revenues have also been cut in half. Even with CARES funding, small business loans and telehealth payment parity made available, it has been a struggle for this group of providers. Recently, the HHS provided nearly $6 million in funding for COVID-19 training and technical assistance activities to 52 state and regional Primary Care Associations (PCAs), which support non-profit and safety net primary care providers. While this is certainly a welcome lifeline, it covers only a small segment of providers and services and doesn’t address the administrative burden that is particularly onerous for primary care.

A recent survey indicated in May that many practices are at risk of closing in a matter of weeks. Specifically, 45% report layoffs and furloughs, 28% skipped or deferred salaries and 14% have temporarily closed – numbers that have remained constant. In fact, one tool projects a catastrophic loss of family medicine physicians by the end of June – almost 60,000 fewer, leaving over 1,800 shortage area counties.

Mixed telehealth success

While many providers have rapidly deployed telehealth and virtual care to continue to serve patients and minimize their financial impact, reimbursement hasn’t always followed and some patients struggle with accessibility. The survey previously cited further revealed 84% of providers report patients struggle with virtual care, and only 57% say more than half of the care they provide is reimbursable while 18% have been denied reimbursement for virtual and telehealth.

Patient care delays

While the current phase of reopening holds out hope for improving these issues, there continue to be areas of concern. Particularly, patients have been and continue to delay essential preventive and maintenance care due to financial issues. This situation has been growing along with the proliferation of high-deductible health plans. And, once again, the pandemic has aggravated it into a potential crisis.

One recent survey indicated a third of consumers plan to reduce their healthcare spending. And, unfortunately, “consumers with complex chronic illness and those in healthy families were more likely than other groups to say they would adjust their spending on healthcare visits or medications.”


Altogether, these concerns are worsening a perennial challenge for primary care providers: burnout. A survey conducted last year indicated 79% of primary care physicians experience burnout, compared to 68% of physicians overall. A study published this year explains why the current crisis is intensifying the burn: too little time with patients, overwhelming paperwork, emphasis of profit over patient care.

Researchers expressed concern about the extraordinary burden COVID-19 has placed on these professionals. “These findings tell us that we need to prioritize understanding and addressing clinician burnout at a system level and at a local level. The human cost, as well as significant physician shortages expected in the future, make this a critical public health concern.”

Threats to the Future of Primary Care

Demand for primary care providers is increasing more rapidly than supply, and provider availability is seen as one of the top barriers to meeting the healthcare needs of patients in this country. In 2013, 53% of states were already experiencing primary care physician (PCP) shortages. By 2025, experts expect that shortage will include 72% of states.

The number of doctors going into primary care continues to decrease in favor of better-paying specialties. And consolidation – in the form of doctors employed by health systems or payers, or joining larger practices – continues to increase, which further decreases provider access and drives up healthcare costs.

Another factor contributing to the primary care shortage is our rapidly aging population. For one, physicians themselves are growing older. Fully one-third of currently practicing physicians will be over retirement age in the next decade. In addition, seniors are a rapidly growing segment of the population, increasing by 50% over the next decade, and tend to require two to three times more healthcare than their younger counterparts. At the same time, there continue to be reports of primary care physicians exiting Medicare, due to lower reimbursement combined with higher administrative burden to participate.

In fact, there is some evidence of primary care providers dropping out of onerous reimbursement arrangements entirely in favor of more predictable compensation models. So-called “membership medicine” like concierge or direct primary care (where patients pay upfront fees for access to doctors) is a small segment of how these physicians practice but is growing in popularity, especially in affluent areas.

What providers encompass “primary care”?

When you think of “primary care” you may be only thinking of your family doctor. But primary care includes a broad spectrum of credentials – doctors, nurse practitioners, nurses, pharmacists – and a range of specialties that fulfill the general medical needs of patient populations:

  • Family medicine
  • Internal medicine
  • Pediatrics
  • General OB/gyn
  • Gerontology
  • Behavioral health
  • Community health
  • Optometrists

How Health Plans Can Respond to Primary Care Challenges

The future of primary care stands to impact all areas of quality and satisfaction in healthcare but, perhaps most relevant and impactful for health plans, are the ways it affects short-term and long-term healthcare costs. According to an expert on the intersections between public health, primary care, and health care policy, “If you think that investing more significantly in primary care and preventive public healthcare is expensive, try not investing. That’s way more expensive. And not just economically, you’re also ignoring the suffering that goes on as well.”

In addition to the potential increased costs, consolidation is also not preventing a loss of primary care providers. As the new president of the AMA relates, “The recent issues during the pandemic with physicians who are employed by large health systems not being able to get the PPE that they need, being disciplined for wearing PPE in certain situations, being furloughed, being laid off, being disciplined just for doing what they thought was best for their patient, I think, highlights the importance of physician autonomy.”

In the face of these challenges – impacting payer bottom lines, member satisfaction and health, and provider networks – health plans have a few avenues to pursue in shoring up this cornerstone of the healthcare system. Here are 4 ways that payers can respond to primary care challenges:

1. Extend telehealth

Health plans providing leeway on virtual care has been a real boon for providers and their patients. But, along with extending telehealth payment parity, effectively communicating those changes and appropriate education really makes this benefit useful. The leader at a technology provider for clinician practices noted, “Most physicians don’t even know how to code correctly for the phone call or virtual visit to take advantage of the changes Medicare (and other payers) have made during the pandemic to increase phone call reimbursement and pay for telehealth visits at the same rate as in-person visits.”

2. Promote value-based care contracts

We wrote before how those providers who were already engaged in alternative payment models were better prepared to weather the patient volume dips associated with the pandemic. Primary care providers seem especially suited to this model because of their role in preventive care and unique ability to screen for social determinants of health and impact overall patient care outcomes. For health plans positioned with advanced technology to offer real-time communication, two-way data exchange, and telehealth flexibility, their primary care provider networks should be better prepared to withstand perceived risks and more open to these modern arrangements.

CMS is already piloting the Primary Care First project with similar structure and goals. The program covers a variety of providers – MD, DO, CNS, NP and PA – and will be active in 26 regions across the U.S. With a simple flat fee payment structure plus upside revenue sharing, it aims to reduce primary care practitioners’ administrative burden to allow them to focus on effective care and the doctor-patient relationship.

3. Continue prepay payment integrity efforts

When it became clear how seriously the pandemic was affecting providers, health plans fast-tracked their plans to transition more payment integrity efforts prospective. Because post-pay audits increase the provider administrative burden and increase costs for payers as well, this move to prepay is a trend that’s here to stay. Especially when combined with provider education and two-way communication, supported by an engagement platform like Pareo Provider, this activity should increase engagement with valuable network providers.

4. Support and engage providers

With the understanding that without providers, there is no effective healthcare system, health plans have been directly supporting providers financially. While this effort is admirable and well-intentioned, it is a short-term solution. But extending technology and policy to reduce providers’ administrative burden promise to offer long-term relief.

The work providers have to perform in EHRs is particularly burdensome, with primary care providers particularly hard hit among specialties. With around 20 minutes per patient visit, on average, dedicated to this administrative task, it’s an outsized contributor to burnout and minimizes primary care availability. And this time doesn’t even include pulling medical records for health plans’ payment integrity needs. With real-time communication and seamless data exchange – supported by advanced technology platforms like Pareo – health plans can promote interoperability and reduce cumbersome administrative tasks.

One health plan has launched a new partnership with this intent. This arrangement consolidates all necessary medical records and administrative processes like prior authorizations into one place. By allowing for a quicker and more structured view of patient information, it should reduce documentation time in favor of patient care.

Pareo Transforms Engagement in Healthcare

Even before the global pandemic hit our shores, the healthcare industry had been focusing on innovating in the face of coming disruption. Pareo was created with this initiative in mind, supporting health plans at the top of this chain to transform engagement in healthcare. The integrative technology platform may start with payment integrity, but it extends to real-time communication with providers – including primary care – to reduce their administrative burden and add to the time they spend caring for members. It’s an effort with real implications in reducing healthcare costs and improving outcomes.


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Health Plans Return to Payment Integrity

Health Plans Return to Payment Integrity

3 claims trends associated with the healthcare industry getting back to business, and how health plans can smoothly resume payment integrity efforts.

Now that the crisis-volume of COVID-19 cases has started to ease across the country, delayed elective procedures and in-person provider visits are beginning to resume. While providers return to some semblance of normalcy, health plans are returning to business as usual as well. Our health plan clients are making moves to resume retrospective payment integrity audits they paused in order to relieve the provider administrative burden. What does “back to normal” look like for the healthcare industry, and how can health plans do a health check on the lingering symptoms of the pandemic to ensure their return to cost containment operations goes smoothly?

The “Great Pause” Brings Clarity for Health Plans

While providers have borne the brunt of the pandemic, health plans appear to have weathered the first months of COVID-19 relatively unscathed – or have they? Even in the short-term, there have been significant changes for health plans. Changes such as receiving more telehealth claims than ever before, heightened data security challenges, and facing rapid upheaval of processes in an already administratively complex environment. What’s more, they have risen to the occasion to support their network providers and members, who have suffered significant hardships during this time.

In addition, with the dramatic reduction in healthcare encounters, overall claim volumes have dropped as well, especially for those insurers whose populations reside outside of virus hotspots. Taken alongside pledges to accelerate payments to providers and reduce their administrative burden by minimizing claims recovery efforts to only the most egregious cases, this situation has left payment integrity departments with more breathing room in their day-to-day than usual. And it couldn’t come at a better time. 

During periods of great uncertainty like the industry is experiencing now, the most critical skill is adaptability: being able to focus on surviving in the current moment while also building toward thriving in a future that will look different. Increasingly for health plans, innovations to survive in the short-term and thrive long-term look like technology – including both novel uses for existing tools and new solutions to address new (and old) challenges.

These were trends before the coronavirus pandemic, and the urgency of the situation has only magnified technology’s importance in supporting members, offering work environment flexibility and reinforcing relationships with providers. As the chief medical officer at one large regional health plan explains, “We need to be more open to change, step out of our comfort zones and embrace the unfamiliar. Barriers that have stymied innovation in healthcare aren’t as insurmountable as we once thought.”

Increased Healthcare Utilization Results in 3 Claims Trends

Now that health plans have navigated through the short-term impacts and are putting plans in place to position for long-term success, they are better prepared to adjust to the new normal of healthcare. A recent survey indicated that 80% of payer respondents expect a sharp increase in claims over the next few months. For payment integrity departments, that signals a return to processing claims as before, even as some changes in healthcare utilization are expected to continue for a while. Here are 3 claims trends health plans can look out for in the next phase of reopening.

1. Resumed elective procedures, ER and outpatient visits

The state bans on elective procedures relaxed at the end of April, and patient activity is responding accordingly, albeit slowly. One survey indicates 70% of patients have rescheduled procedures for the second or third quarter of 2020, which holds true across all regions of the U.S. With that resumption, though, sites of care are changing with patients less willing to visit inpatient hospitals. Hospital outpatient settings, ambulatory surgery centers and a physician's office were preferred.

In addition, emergency department use and physician visits best conducted in-person are also rebounding. ER visits, which dropped 42% during April, have recovered 21-32% of volume, depending on patient age. Outpatient volumes recovered over 50%.

As procedures and face-to-face encounters resume there is a concern that the delay may have caused conditions to worsen, resulting in more complex and costly claims. In one survey, “more than one in ten of those who skipped care reported that their condition declined because of their decision to postpone care.”

2. Continued telehealth, home health claims

For the rest of patients whose maladies can be managed and addressed remotely, telehealth and other modes of virtual care are still a popular option. Its use increased more than 4,000% over the last year, growing from 0.17% of medical claim lines to 7.52%. Now that consumers – and their providers – have been prompted to try it, they have found telehealth lives up to its promise of convenience, without unduly limiting the effectiveness or person-to-person connection of the visit. It also comes at a lower cost, and a new report estimates at least 20% of care could be offered digitally.

Home health, too, has found its moment for patients who, for instance, regularly receive infusion treatments, need dialysis or require post-operative care. These trends have accelerated due to advances in at-home technology along with payers temporarily relaxing restrictions. However, whether these prove to be temporary changes or a permanent shift remains to be seen.

3. Increased behavioral health utilization

The stresses of living during a global pandemic, along with increased social isolation due to stay-at-home orders, have negatively impacted mental health conditions for many Americans. Prescriptions for antidepressants, anti-anxiety and insomnia medications spiked in the first months, many for first-time use. At the same time, while inpatient mental healthcare capacity and utilization has dropped, many patients have taken advantage of virtual mental health visits.

One technology vendor executive attributes this increase to reduced stigma associated with telehealth, along with greater availability. That is a hopeful sign for wellness initiatives, and because counseling is one of the specialties more readily covered by telehealth even before the pandemic, this trend may continue indefinitely.

How Health Plans Can Improve Payment Integrity Agility

With the understanding that healthcare may be in flux until a reliable vaccine and/or treatment for COVID-19 is available, health plans are returning to their claims recovery efforts with sensitivity to how this activity affects providers and members. This transition requires agility, which is a cultural initiative and skill. As a leader at a large state-based health plan says, “We put these skills into action during the COVID-19 pandemic, making decisions rapidly to respond to the needs of our members and providers.”

Responding to member and provider needs with tech innovations

Adjusting to the rapid changes in healthcare to be responsive to member and provider needs may start with a culture shift, but technology is the enabler. Providers and members both are still reeling from the coronavirus impact, and health plans are best positioned with real-time data to promote seamless communication and continue the shift to prepay.

Real-time data provides the insights needed to determine how and when to adjust the response. Health plans can leverage an integrative platform like Pareo to ingest data feeds from multiple sources for a fuller view of the claims environment. It’s a first step towards interoperability, which supports both members and providers.

Seamless digital communication follows. At some point, health plans will begin to roll back the financial relief they have been extending to members and providers. The waived copays and cost sharing for coronavirus testing and treatment. The relaxation of prior authorization requirements. To ensure members and providers don’t end up holding the bag due to lack of knowledge, seamless two-way digital communication is key. Both internally with payment integrity departments and externally with members and providers.

Pareo Provider includes a web-based portal designed to engage with providers on claims status, education, medical records exchange, data sharing and other relevant two-way communication to foster this valuable partnership. Request a Sell Sheet

Prepay claims processing has come into its own during the healthcare crisis to reduce abrasion with providers. It’s more sustainable than accelerating payments and CARES funds, which have many strings attached, and reduces the costs associated with reworking claims – for both payers and providers. While post-pay payment integrity audits will never cease entirely (combating healthcare fraud, in particular, is largely a post-pay activity), minimizing the administrative burden of “coming from behind” to adjust payments in favor of more prepay work is a trend that’s here to stay.

Pareo Prepay supports this shift from pay-and-chase to working claims before payment with a concepts repository accessible across the payment continuum and configurable workflows that easily accommodate tight prepay timelines. Request a Sell Sheet

The Bigger Picture

Innovations in payment integrity have long been a goal at health plans. Health plans that we speak with continue to drive home the importance of data at this crucial time, to provide a measure of predictability during a situation that’s far from certain. Yet, connecting data from disparate streams and collapsing it into usable insights – insights which can be drilled down into – is still far from available to many health plans.

Imagine a platform in which your entire payment integrity operations are fluid, accessible, operational – in real time. Imagine accessing configurable reporting that offers actionable insights, tracks KPIs, and connects previously disparate data streams.

Advanced technology platforms like Pareo put this goal within reach for more payers – not just those with vast resources at their disposal. Pareo now more than ever has the chance to revolutionize the healthcare industry. Are you ready to learn more?


See the ClarisHealth 360-degree solution for total payment integrity in action: