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:

Health Plans Launch Innovative Solutions to Respond to Mental Health Crisis

Health Plans Launch Innovative Solutions to Respond to Mental Health Crisis

Transparent data sharing supports seamless care coordination, relevant outreach that mitigates effects of chronic conditions.

The novel coronavirus pandemic continues its near-perfect record as a harsh but effective teacher for the healthcare industry as it efficiently evolves systemic weaknesses into full-blown crises. Patient and procedure volume-based reimbursement structures? Check. Primary care access? Check. Healthcare coverage? Check. Now we can add the mental health status of Americans to that list. But, even with these issues, the ability to steer through the challenges and find our way to an appropriate solution is still within reach. And payers, with their increasing focus on whole-person care, are particularly suited to drive these changes.

How can health plans promote improved access and outcomes in mental health while controlling costs associated with this expensive chronic condition during the pandemic and beyond? And what are the implications to health plan payment integrity operations? Let’s explore the landscape and potential solutions.

Challenges: Access and Expense

It’s estimated that 1 in 5 Americans suffer from mental health issues. It’s a problem that’s already been increasing in severity across our population, especially among teens and young adults. But with the onset of the pandemic, there are signs that figure may be increasing dramatically.

Increased isolation, grief, job losses, pressures from juggling home/work/childcare responsibilities, extended uncertainty and more are creating and worsening anxiety and depressive disorders. And, among frontline healthcare workers and other essential employees, in particular, there are concerns with potential long-term PTSD-akin effects. Experts predict an associated increase in suicides, overdose deaths and substance use disorders as well.

Why are these rising cases such a concern? There are two big perennial challenges associated with mental healthcare.

Limited access to care

Without proper intervention and maintenance, there is risk of situational mental health issues becoming chronic and existing mental health conditions becoming increasingly severe. But while 20% of Americans experience mental illness, historically less than half receive treatment. This limited access to appropriate care has a variety of causes. While there are cultural barriers – concern about perceived stigma, for instance – structural barriers are just as restrictive.

At least 60% of U.S. counties don’t have a single practicing psychiatrist, so even for those patients covered by insurance, access is an issue. They struggle to find in-network mental health providers that will take their insurance. One study found that these patients with commercial insurance were up to 15% more likely to receive out-of-network care than other chronic disease patients, and their cost burden was almost 4 times higher.

And, for those who have managed to get treatment, the pandemic has limited their in-person visits and put their providers in a precarious financial position. Already vastly underfunded, fragmented and difficult to access, mental health providers have been just as impacted financially as other healthcare providers. But because relief funding is largely based on Medicare rates, rather than Medicaid, community behavioral health centers were less likely to pursue and receive support.

Mental health and addiction providers estimate they will lose $38.5 billion in revenue in 2020, and more than 60% of providers had already been forced to close at least one program before the end of April. Close to half of mental health and addiction providers report their chances of survival at 6 months or less in the current fiscal climate, minimizing their ability to act as a safety net when they are needed most.

Expensive to manage

Mental health conditions negatively impact quality of life and economic productivity, which are grave enough consequences. But in addition to the healthcare industry lacking sufficient mental health resources, it is also one of the more expensive chronic conditions to manage. In 2019, the U.S. spent over $225 billion on mental health services, or 5.5% of total healthcare spending, and that dollar amount has increased over 50% in the last 10 years.

Direct spending on mental health services doesn’t paint the full picture. Mental illness is disproportionately associated with physical chronic conditions as well – cardiac, pulmonary and obesity comorbidities. In fact, depression quadruples the risk of a heart attack. And taken together, these issues create a much bigger impact. According to the CDC, 90% of national healthcare spending goes towards managing chronic conditions and mental health.

Approximately 75% of those with severe mental illness (SMI) have at least one chronic physical ailment, and the number increases among vulnerable populations. One 14[study] of Medicare beneficiaries found 12.7% of spending was associated with mental health disorders, but mental health services only made up 4.2%. In fact, patients with an SMI reflected a 37% increase in physical healthcare costs, and an 18.4% increase for those with other common mental health disorders.

Opportunities: Telehealth and Whole-Person Care

Even with these systemic challenges associated with mental healthcare, promising signs have emerged that hold the potential to mitigate their effects, including rapid adoption of telehealth and payers increasingly focused on whole-person care.

Accelerated virtual care adoption

Telehealth use already found its niche in behavioral healthcare, especially in underserved areas. But with the stay-at-home orders, telehealth claim lines increased more than 8,335% from April 2019 to April 2020. Mental healthcare was a big driver of those visits, but chronic condition management made big gains in virtual care adoption as well.

Teletherapy offers distinct advantages for mental health patients, not the least of which is extending access to mental health providers when availability or convenience is an issue. It also eliminates the need for travelling to an appointment, allows for a familiar environment and may even mitigate concerns of stigma. Mental health providers, too, see benefits by gaining insights into the home environment and allowing patients to more easily maintain valuable therapeutic visits.

Even though many patients had little to no experience with telemedicine or other forms of virtual care, most have been pleased with the encounters and want to see it continue indefinitely. And, in the same way payers have seen success with virtual care for monitoring and managing physical chronic conditions – and creating patient trust in the process – there is reason to expect similar results with mental health conditions.

Increasing focus on whole-person care

Health plan models are increasingly centered around improving the delivery of person-centered care. How can you treat the whole person and engage provider, patient and other stakeholders after the encounter? Two different models of coordinated care for better integrating mental health are common.

Co-location of services – where mental health and primary care providers physically exist in the same place – offer economies of scale, efficiency and improved outcomes that benefit health plans. Looser collaboration agreements don’t require a provider organization to deliver the full array of services, provided they work closely with others across the service delivery ecosystem to ensure coordinated access to care, but does necessitate a technology infrastructure that supports true data interoperability.

For health plans, both models see the full array of services – for mental health and physical healthcare – covered under a single agreement with a goal of positively impacting utilization and health outcomes. And new clarity on privacy regulations makes it more straightforward for providers to coordinate care for those patients suffering through a crisis.

Innovative approaches to coordinated care promise to unlock value for payers, providers and consumers by supporting alternative reimbursement models; offering leeway on care modalities to include telehealth, remote patient monitoring technologies, and care management home visits; and providing real-time care integration. Many health plans are relying on integrative technology solutions as a backbone to power a seamless patient care experience, and these benefits extend to behavioral health.

Advanced Technology Enables Relevant and Sustainable Solutions

While the challenges – and opportunities – are significant, health plans don’t have to pioneer entirely new programs in order to improve systems for mental healthcare maintenance and intervention. Engaging members and providers via current advanced technology initiatives can strategically extend this function.

Member engagement

A new poll confirmed what we already feel to be true as consumers: the healthcare industry is simply too complex to navigate effectively. Respondents overwhelmingly cited every aspect of healthcare – care access, management, and payment – as needing to be streamlined and simplified. “They want health plans and providers to end the fragmentation, simplify the experience, and deliver a fully connected encounter that makes healthcare as seamless as any other online endeavor.”

Arguably, the system proves to be even more unnecessarily opaque for those experiencing mental health issues and their support system. And those with mental health disorders are at higher risk during the pandemic. Many health plans already prioritize seamless member engagement opportunities, supported by modern communication modalities. But, as we wrote in a previous article, consumers want to hear from their health plans more, especially with relevant information. One payer program of this type is already seeing the benefits.

Additionally, more advanced solutions like population health management platforms, such as that offered through Pareo, allow you to proactively assess disease risk among your membership. Taking this opportunity to reach out to members about their telehealth options, the importance of medication adherence, information about prescription assistance, wellness options, chronic disease management, checking in with a primary care provider, how to better protect themselves from COVID-19 and more promises to yield significant dividends.

Provider engagement

Many behavioral health providers and facilities still receive most of their revenue from fee-for-service reimbursement, but from there member experience can unravel. Some payers will not give reimbursement checks to a facility directly, but rather to the plan member. This can create abrasion between the patient and provider as well as the provider and the payer, but that risk can be mitigated through strategies like prospective cost avoidance and coordination of benefits.

However, in order for mental health providers to shift revenue management strategies, health plans need to be in a place where they can support prepay. Pareo is a seamless payment integrity solution that can power retrospective and prospective claims recovery. It does this in part through automated workflows and by housing relevant medical claims data, enabling plans to hold up their end of prospective cost avoidance.

Related to mutually beneficial payment structures, a survey conducted in March 2020 indicated 74% of primary care organizations and 61% of behavioral health organizations participate in some form of value-based reimbursement. But, only 16% of those organizations have 20% or more of their revenue in such an agreement. With health plans looking to accelerate adoption of alternate payment models, it’s important to keep in mind what’s essential to their acceptance and ultimate success.

Extending clinical data interoperability, integrated workflows, proactively identifying gaps in care, and real-time metrics are key components of modern value-based contracts. When health plans better engage with mental health providers, those providers are empowered to better support members. And transparent data sharing – like that supported by the integrative platform Pareo – extends health plans’ abilities to do exactly that.

Pareo Provider is a seamless technology platform for real-time engagement with providers, including specialty providers. Not only for the purposes of payment integrity – though Pareo effortlessly accommodates complex reimbursement contracts and supports two-way communication on claims. But also new information on virtual care allowances, sharing quality metrics, getting credit for SDOH assessments and more – without increasing the provider or payer administrative burden.

Pareo is a Single-source Solution for Payment Integrity Operations

Understanding trends in behavioral health management is vital to health plans, and payment integrity teams must take note of the implication of mental healthcare utilization on their operations. With only half of those who suffer from mental health conditions receiving care, and many members eligible for care struggling to find access to providers, complexities abound. Further, many mental health providers and facilities are using outdated payment models, because before the Affordable Care Act, mental health was often not a covered health insurance benefit.

Pareo is a single-source payment integrity solution that can integrate with myriad data systems to power even the most nuanced retrospective and prospective claims recovery efforts. Within Pareo, features that support provider engagement, population health management and prepay can facilitate (and automate) facets of behavioral health claims management to create a better experience for payers, providers and most importantly – patients.


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

Coronavirus Boosts Telehealth Adoption

Coronavirus Boosts Telehealth Adoption

The COVID-19 pandemic prompts payers to encourage the shift to telehealth, a move supported by patients and providers. How will this change the future of healthcare delivery?

The novel coronavirus stopped traditional healthcare in its tracks, but there’s one bright spot: telehealth. As technology has advanced over the last several years, it seemed as though at any moment, telehealth would finally take off. But while the market size of the telehealth services industry growth has outpaced other areas of healthcare, with 25% average annual growth from 2015 to 2020, relatively few of us have experienced a virtual healthcare visit. That is, until now.

Recognizing the potential of telehealth to provide safe and continuous care to those in need – both potential COVID-19 patients and those in need of other non-emergent healthcare – the CARES Act stimulus package offered $200 million through the Federal Communications Commission to medical groups to help them install the technology and fund broadband installations. At the same time, CMS and commercial health plans have temporarily introduced payment parity and relaxed some regulations that have traditionally held back progress on the initiative.

These interim changes and financial support have dramatically increased provider, patient and payer experiences with telehealth, and early surveys indicate general satisfaction and acceptance. What does this mean for the future of telehealth? Here, we explore how telehealth has evolved in recent years, including traditional barriers to adoption, and how the pandemic has accelerated the way forward.

What is telehealth?

The Center for Connected Health Policy defines telehealth as “a collection of means or methods for enhancing health care, public health and health education delivery and support using telecommunications technologies. Telehealth encompasses a broad variety of technologies and tactics to deliver virtual medical, health, and education services. Telehealth is not a specific service, but a collection of means to enhance care and education delivery.”

While the term “telemedicine” is used for traditional clinical diagnosis and monitoring delivered by technology, telehealth is used more broadly to cover the wide range of diagnosis and management, education, and other related fields of health care, including dentistry, counseling, physical and occupational therapy, home health, chronic disease management and more. It also covers live video visits, mobile health data, remote monitoring via connected devices and store-and-forward technologies for secure sending of health information.

Barriers to telehealth adoption

Even before the novel coronavirus pandemic took hold, telehealth was slowly expanding, but there were numerous challenges to its widespread adoption, the biggest of which were complex regulatory barriers and lack of payment parity.

First, regulations vary depending on CMS, state Medicaid, and state commercial health plan requirements. All are different but restrictions on type of service, location of service (both provider and patient), provider credentials, cross-state visits and/or state licensure and more are common. That said, according to a recent survey, 42 states and Washington, D.C., now have some sort of telehealth commercial insurance coverage law, an improvement over the last five years. However, only 10 states offer true payment parity, which disincentivizes providers to offer it.

As a result of this complexity, telehealth has been minimally available to consumers until recently. In a 2016 survey, over half of consumers surveyed indicated they wouldn’t use telehealth and 39% said they hadn’t even heard of it.

Historic resistance to telehealth

Payers and other entities have historically resisted adopting measures that would expand telehealth adoption by limiting reimbursement and the number of eligible procedures as well as enacting

various provider restrictions. A 2018 hearing regarding a Connecticut telehealth bill illustrates the concerns about payment parity. The legislation was supported by providers, but payers and employers opposed the payment provisions citing their desire to negotiate reimbursement themselves as well as arguing that telehealth should fundamentally be a lower cost option.

A more recent debate holds state medical boards responsible for holding back telehealth progress with their role in continuing to forward credentialing, cross-state and established relationship restrictions. While concerns about malpractice and liability are valid, it’s difficult to say if patient safety is more at risk with telehealth.

The same argument holds for potential fraud. Though the telehealth industry argues virtual visits are no more susceptible to fraudulent activities than other healthcare encounters, regulators hold that these restrictions are necessary guardrails because of the increased capacity. As one official with the HHS Inspector General’s Office states, “There are unscrupulous providers out there, and they have much greater reach with telehealth. Just a few can do a whole lot of damage.” Health plan SIUs likely will need to adjust metrics currently used to find fraud in in-person encounters, as legitimate telehealth claims may look like previously “impossible visits” regarding provider capacity and geography, for instance.

Telehealth benefits during the pandemic

The novel coronavirus pandemic has quickly demonstrated the significant benefits of telehealth – both for patients and providers – and thus its market viability. While the pandemic has accelerated telehealth use, one survey indicated that telehealth was already beginning to really take hold with over a third of Millennials and Gen Xers taking advantage of virtual visits. The survey also demonstrates the potential of telehealth, noting that, “based on actual claims costs and coding over the two-year study, approximately 71% of convenience and urgent care visits could have been virtual visits, saving ... $3.8 million, or 45% of allowed costs.”

A story out of Pennsylvania illustrates telehealth’s unique benefits for the management of chronic disease, especially for an area with a huge rural and elderly population. Telehealth visits for the region’s largest healthcare provider jumped 3700% from early March to late April. While there were technical challenges for both patients and providers in the beginning, “the satisfaction rate among patients is remarkably high.” They are working on documenting the outcomes during this period to prove the technology’s viability for long-term use, which may be particularly useful for health plans looking to expand risk-based contracts.

Recent surveys also reveal the pandemic’s impact on physicians and their response. One showed that in-person healthcare visits were down by 67% while overall visits decreased by 54%. However, of the total ambulatory practice visits, 30% were delivered through telehealth, and half of physicians now offer telehealth, up from only 18% two years ago. With 20% of surveyed primary care practices at risk of permanent closure due to the pandemic, many are turning to telehealth to provide continuity for patients as well as to bridge the financial gap. As one physician noted, “The process allows them to keep open that virtual front door in a meaningful way."

Telehealth moving forward

So, what’s the fate of telehealth post-pandemic? Bipartisan legislation introduced in October 2019, the CONNECT Act, aims to reduce barriers to telehealth in Medicare, so there is existing support. Additionally, the current situation presents CMS, state Medicaid administrators, state medical boards, and commercial payers alike with several considerations.

Now that consumers have been able to experience the convenience of telehealth for themselves, they are unlikely to desire a return to the “old way.” Even the elderly population has taken advantage of the safety and flexibility offered by virtual care from their homes. And, combined with payers’ historic focus on digital technology that supports member satisfaction initiatives, health plans may be open to extending telehealth coverage now that consumers are embracing it.

In addition, more providers have invested in telehealth capabilities to support operational continuity, which reduces infrastructure barriers and promises to mitigate the foretold provider shortage. Because the novel coronavirus has put undue stress on the physical and operational health of providers, continuing the relaxed telehealth regulations indefinitely may prove to be the right move.

This situation provides an ideal proving ground to test how payment parity and minimizing restrictions affects patient care. If all proceeds without dire consequences, it will be difficult to put the genie back in the bottle.

Health plans turn to Pareo

Expanding telehealth coverage can no doubt add complexity to an industry that is already shouldering a great deal during this time. Adding to the significant administrative burden of health plans and providers is unsustainable. During the pandemic and beyond, health plans can no longer deny the numerous benefits of digital transformation. Advanced payment integrity technology platforms like Pareo allow payers to support rapidly changing provider contracts and payment policies and seamlessly engage with providers.

While the expansion of telehealth at such a rapid pace is a new development, most payers have long-anticipated a shift to digital care to improve patient access and intervention for value-based care initiatives and other healthcare cost savings measures. However, health plans who are not agile in data sharing, accessing relevant business insights, or even vendor management may struggle to modernize operations fast enough.

Administrative burden is a problem that most payers have yet to solve, and the quick expansion of telehealth is sure to exacerbate the issue. Pareo is unique in that it not only unites disparate systems and automates workflow (solving many efficiency problems), but our payment integrity technology also sets the stage for health plans to own the core operations that power revenue. Our clients have seen up to a 10x return on investment, with efficiency gains estimated at 25-50%.


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