How to Evaluate Payment Integrity Solutions: The Ultimate Guide for Health Plans

How to Evaluate Payment Integrity Solutions: The Ultimate Guide for Health Plans

Payment integrity solutions vendors make many claims. Here are the top 14 areas of evaluation to ensure a perfect fit for your health plan.

Virtually every health plan is looking to address shrinking margins by moving their medical savings from a typical 1-2% today to something above 5% over the next few years. At the same time, the amount of healthcare data is only expanding, making that goal more difficult to address with current solutions. Are you prepared to thrive in this increasingly complex environment? You may find it’s time to evaluate payment integrity vendors and solutions.

Most of the health plans and payers we talk with are in one of two camps: a few self-developed solutions for claims audit and recovery, or scores of piecemeal applications used by the assorted departments dedicated to different areas of cost containment.

No matter your current approach, health plans have an increasing number of advanced technology choices in front of them, all promising “the answer.” New solutions emerge every day to address your interoperability, data and analytics challenges. As your options expand, so do your chances of finding the right fit for your organization – or the wrong one.

What’s at stake? Your rate of recovery.

Choosing the right payment integrity solution for your health plan holds arguably the greatest potential impact on your bottom line. When ClarisHealth conducted a survey examining payment integrity returns on claim spend at the leading national and regional health plans, we discovered a key difference. Those payers who had a scalable technology solution in place more than tripled their rate of recovery. Those that depended on outdated applications that require a great deal of manual intervention just couldn’t compete.

As your health plan looks to evaluate payment integrity solutions emerging on the market, three questions will guide you in your search:

  • What are the most important elements of functionality to consider to address your needs – now and into the future?
  • Is the goal a single, integrative platform to replace manual and piecemeal tools, or an assortment of upgraded solutions?
  • How do the different options – payment integrity platforms, self-developed technology, claims editors, fraud tools, third-party services providers – stack up against each other?

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

Functionality is the Top Consideration

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

1. Supplier Optimization

Services vendors are a big part of most cost containment strategies. So, the ideal payment integrity solution should optimize the value you receive from third-party suppliers. Look for functions like overlap control, contract management and performance reporting all integrated through a single platform. Onboarding a new payment integrity supplier should also be quick and easy. With this functionality in place, you should expect to realize, on average, a 30% increase in supplier efficiency.

2. Audit Workflow and Analytics

If you want to internalize more payment accuracy efforts, you should prioritize functionality that assists in maximizing advanced analytics and hit rates. Look for access to insights needed to create internalization strategies around cost optimization in both pre- and post-pay environments. Because workflows differ greatly between payers, ensure configurability in this area to integrate vendor and internal recovery management efforts. Full visibility on auditor throughput and automation to eliminate routine administrative tasks that bog down valuable staff hours are also key. Altogether, this functionality could boost your internal analyst activity 3x.

3. Clinical Workflow and Analytics

Concerns about increasing provider friction keep health plans from taking full advantage of the skilled clinical coders and nurse auditors on staff. The ability to coordinate seamlessly between vendors and internal resources on provider outreach to prevent overlap, internalize the best analytics from all sources, and fully reconcile each audit removes that limitation. In addition, look for A.I.-powered solutions that unlock unstructured text in the medical record to prioritize claims for review. This advanced functionality could decrease your medical expenditures by 2-4% and reduce the chance of errors.

4. Prepay Workflow and Analytics

With as few as 15 days to make a pay/deny decision on a claim, many health plans choose to “pay and chase.” But with time and quality improvements, health plans can move more audit work prepay. Seamless integrations with data sources, post-pay and service vendors will allow for comprehensive audit management. As will automated workflows and clear visibility into timelines and hit rates. Also look for the ability to extend the most successful post-pay concepts to prepay and take advantage of multiple detection sources. With comprehensive payment integrity technology in place, your health plan can put greater focus on internal prepay avoidance, and a 10% improvement is common.

5. Fraud Detection and Case Management

Relying solely on rules-based detection and fragmented case and allegation management tools that silo data unnecessarily stifle the effectiveness of SIU teams. Consider a comprehensive solution that bridges the audit and investigation divisions of your health plan while maximizing efficiencies with case tracking, investigations, and federal and state reporting. Also look for detection capabilities powered by artificial intelligence to dramatically reduce false positives, focus efforts on most likely leads, and surface novel schemes.

Annual spending on artificial intelligence in healthcare estimated to reach be more than $34 billion in 2025. A recent survey of healthcare organizations found 98% have implemented an A.I. strategy or plan to develop one. And 59% of healthcare leaders expect to achieve a full return on their investment within three years. “Will Artificial Intelligence Finally Make Good on Its Promise to Healthcare?”

6. Reporting and Business Intelligence

Actionable business intelligence allows health plans to drive maximum efficiency and effectiveness. Seek out real-time metrics that can be leveraged for accurate reporting on-demand and configurable role-based dashboards to scale business intelligence solutions system-wide.

7. Provider Engagement

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

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

Get the Checklist

This evaluation criteria is available as a handy download so you can be confident in your payment integrity solution choice.

Additional Considerations to Evaluate Payment Integrity Solutions

A search for payment integrity technology doesn’t stop at functionality questions, particularly as a health plan evaluates various solutions and/or a more comprehensive platform. The feature set alone will not paint the whole picture. To ensure a technology solution meets your needs today and into the future – and fits within the budget – we recommend you look a little deeper.

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

1. Flexibility

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

2. Total Cost of Ownership

Factor in maintenance, annual licensing and setup costs. Also consider how much investment and effort it will take to improve the technology and its adoption. Combined with any potential financial improvements, how will ROI be impacted?

3. Integration and Ease of System Implementation

What training and support does the solution provider in question offer? How often do they update their platform, and how well will it integrate with current and future suppliers and providers? Look for integrations that can be 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 scalable technology stack.

Total payment integrity 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. “Why Health Plans Should Choose a Scalable Technology Platform?”

4. User Friendliness

How intuitive is the technology’s user interface and user experience? Evaluate this aspect from the end user perspective as well as managers and decision-makers. Also consider that cloud-based solutions will differ from on-premise in terms of stakeholder engagement, efficiencies and data accessibility. The healthcare industry is increasingly moving all electronic systems to “the cloud” to reduce capital investments in quickly obsolete hardware.

5. Security

Health plans are rightly concerned about data privacy and security. Your technology vendor should have protocols in place to mitigate these concerns. How easy is it to control users’ access and permissions? Look for technologies that allow for controlling access and permissions at object/table-level, at feature-level, and at field-level as well as an audit trail to track changes. Features like single-sign-on, two-factor-authentication, and the ability to insist on password requirements are also ideal.

6. Working with the Technology Vendor

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

How Does Comprehensive Payment Integrity Stack Up Against Other Solutions?

When we speak with health plans and payers, we find that there’s some confusion surrounding the elements of a robust payment integrity program. Often, they see a claims editor or a FWA tool as a complete payment integrity solution. These tools offer great value but are limited in scope. We regularly uncover gaps and hidden revenue for plans that rely solely on these siloed approaches.

However, a comprehensive payment accuracy platform should seamlessly integrate with these tools to prevent further gaps. Pareo was created to connect external solutions, data streams and third-party services vendors. We recommend you set your benchmark at total payment integrity. But you can use this checklist to evaluate other elements of a payment integrity program.

How to evaluate payment integrity solutions compared to Pareo

Self-developed technology: Self-built payment integrity solutions incur large, ongoing costs for health plans. A self-built solution will require a longer lead time before you can realize ROI. Additional considerations for those considering building an in-house solution are functions that need to be included, expertise, and needed integrations. Pareo can be implemented quickly and offers many immediate benefits to a health plan.

Claims editors: Pareo works in tandem with claims editing solutions by improving their scope and automating much of the workflow.

Fraud tools: FWA solutions, like claims editing solutions, are limited in scope and therefore not comprehensive. They should not be a health plan’s only line of defense in preventing improper payments. If you already use a rules-based tool, you can integrate its data into Pareo.

Third-party services suppliers: A health plan considering third-party vendors doesn’t have to choose between Pareo and their business partners’ solutions. Pareo offers supplier optimization tools that allow for platform integration, improving a payment integrity system’s performance and workflow.

 

NOW'S THE TIME FOR TOTAL PAYMENT INTEGRITY

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

Will Artificial Intelligence Finally Make Good on its Promise to Healthcare?

Will Artificial Intelligence Finally Make Good on its Promise to Healthcare?

Artificial Intelligence is making the leap from much-hyped “trend” for healthcare technology to more widespread adoption. Here’s what A.I. is — and isn’t — and how health plans are proving its value.

Artificial Intelligence for healthcare has come a long way since 2017 when IBM Watson Health, the A.I. supercomputer fell short of its high expectations. A.I. is a powerful force in advanced healthcare technology and is poised to disrupt the industry. And, due to several converging factors in 2020, adoption accelerated. Let’s explore what A.I. is — and isn’t — and why it’s here to stay despite current limitations. But first, a few definitions.

Defining Artificial Intelligence

While varied stakeholders have found value in applications of artificial intelligence for healthcare, confusion remains about what it is and isn’t. When the industry uses buzzwords like “A.I.” and “machine-learning” to describe product functionality, know these words are easily misunderstood and thus, often used incorrectly. Let’s level-set with some working definitions of terms you might encounter when evaluating advanced healthcare technology.

Artificial Intelligence: Intelligence applied to a system with the goal of mirroring human logic and decision-making. A.I. is utilized for the purpose of successful knowledge acquisition and application, which it prioritizes over accuracy. A.I. simulates intelligence (the application of knowledge). It includes many subcategories and is often separated into three types: narrow, general and super.

Narrow Artificial Intelligence: Created specifically for a single task or to solve a single problem. Almost all applications of A.I. In use today are of this type.

General Artificial Intelligence: A type of broad and adaptable A.I. that can think and function just like humans. Not generally available today, though advancements in neural networks may offer a path to this reality.

Super Artificial Intelligence: A theoretical type of A.I. that is imagined to exceed human cognition significantly. It should emerge from the exponential growth of A.I. algorithms self-learning. Does not currently exist.

Machine Learning: An application of A.I. that allows a system to learn on its own. ML learns from data, and it aims to increase accuracy (success is a lesser concern). ML simulates knowledge. Source Includes both supervised and unsupervised methods.

Supervised Models: Algorithms designed to learn by example, based on labeled datasets that provide an answer key that the algorithm can use to evaluate its accuracy on training data. The term “supervised” learning originates from the idea that training this type of algorithm is like having a teacher supervise the whole process. When training a supervised learning algorithm, the training data will consist of inputs paired with the correct outputs.

Unsupervised Models: Machine learning technique that finds and analyzes hidden patterns in “raw” or unlabeled data. By ignoring labels altogether, a model using unsupervised learning can infer subtle, complex relationships between unsorted data that semi-supervised learning (where some data is labeled as a reference) would miss. And do so without the time and costs needed for supervised learning (where all data is labeled).

Data Analytics: Process of examining data sets in order to draw conclusions about the information they contain, increasingly with the aid of specialized systems and software. Data analytics technologies and techniques are widely used in commercial industries to enable organizations to make more informed business decisions and by scientists and researchers to verify or disprove scientific models, theories and hypotheses.

Predictive Analytics: Historical data that has been collected is utilized to try and predict behavior/outcomes (often called Data Science). To analyze data, it is routed into a report, at which point humans or artificial intelligence apply multiple factors to make predictions about expected outcomes. Though based on decades-old technology, “predictive analytics” often implies that a machine has performed the analysis and offered a prediction (rather than a human).

Neural networks: Seeks to simulate human brain processing, which is facilitated by networks of neurons. At its simplest, a neural network processes information in three layers: 1. Input layer where data enters the system, 2. Hidden layer where data is processed, and 3. Output layer where the system decides what to do with the information.

Deep learning: Allows for increasing numbers of layers through which data passes, where each layer of nodes trains on a distinct set of features based on the previous layer’s output. The further you advance through the layers, the more complex the features your nodes can recognize, because they aggregate and recombine features from the previous layer.

Overcoming Concerns About Artificial Intelligence for Healthcare

Though experts have long predicted that artificial intelligence for healthcare would take hold, adoption has progressed slowly. And no wonder. The industry has been historically hesitant in its pursuit of advanced healthcare technology. And for clinical care applications, particularly, providers express discomfort with “black box” A.I.

Forbes points out, “As humans, we must be able to fully understand how decisions are being made so that we can trust the decisions of AI systems. The lack of explainability and trust hampers our ability to fully trust AI systems.”

In addition to explainability issues, lack of broad access to healthcare data stymies effectiveness of A.I. Data silos and patient data privacy concerns both limit access that could push the technology forward. But federated learning could help overcome this barrier. It’s a privacy-focused approach to machine learning that allows companies to collaboratively form more representative data sets without sharing raw data. Once-generic models get smarter over time through decentralized data and decentralized compute power.

This approach could also help overcome another perennial concern about A.I.: model bias. A.I. systems learn to make decisions based on training data, which can include biased human decisions and amplify historical or social inequities. It’s a complex problem with life-and-death consequences in using A.I. for healthcare. But leveraging larger, more varied data sets, increasing transparency of processes, improving awareness of potential bias in A.I. outputs, and continuing to augment machine decisions with human expertise will mitigate this issue.

2020 Makes the Case for A.I. in Healthcare

Early adopters in the healthcare payer sector understand the benefits and risks associated with A.I. all too well, and skepticism of vendor claims of A.I. is high (and rightly so). However, the value of artificial intelligence in healthcare increased significantly in 2020 due to two primary drivers.

First, A.I. compute has been doubling every three and a half months making applications faster and cheaper. In just a year and a half, large image classification systems are training much faster, from three hours down to 88 seconds. Progress on natural language processing (NLP) classification tasks is also “remarkably rapid.”

Second, the novel coronavirus pandemic accentuated the foundational weaknesses in the healthcare system. All at once, various stakeholders around the industry sought A.I. applications to address the resulting challenges. They also found value in collaborating to achieve the data access, sharing and quality needed to power these tools. Solutions for drug discovery and disease prediction emerged at a record pace. And the data and research breakthroughs promise to continue to push the industry forward.

Applying A.I. to Advanced Healthcare Technology

A.I. is expected to permeate every facet of the industry healthcare, with annual spending on artificial intelligence in healthcare estimated to reach be more than $34 billion in 2025, up from $2.1 billion in 2018. A recent survey of healthcare organizations found 98% have implemented an A.I. strategy or plan to develop one.

The current applications of AI in healthcare are narrow and highly functional. But as adoption accelerates, it generates momentum which perpetuates the benefits of A.I. In fact, 59% of healthcare leaders expect to achieve a full return on their investment within three years.

Some current applications of A.I. for health plans include:

  • Detecting and preventing fraud, waste and abuse
  • Value-based care initiatives
  • Claims management
  • Supporting coordination of benefits
  • Surfacing business intelligence insights
  • Increasing effectiveness of clinical audits
  • Member outreach and engagement
  • Automating administrative processes
  • Predicting healthcare needs

“With AI, the more quickly organizations in early or middle stages of AI deployment move forward, the sooner they will overcome uncertainty and unlock the rewards of this powerful business tool.”

So far, no single A.I. vendor has emerged as the leader in the industry. In the coming year, healthcare payers will continue to see technology disruptors enter the market. For many plans, a selection of effectively managed vendors will be the most effective strategy to drive ROI. Though health payers will have to be careful of hype, particularly from tech vendors of artificial intelligence solutions for healthcare who lack industry experience. What works for one sector — say, finance — does not easily translate into healthcare, which is often more complex, more heavily regulated, and more data sensitive.

How Your Health Plan Can Find Value in A.I.

You might think that being a fax/email/spreadsheet organization means your health plan is woefully out of date, but you might not be as behind as you fear. Even as the early adopter stage of A.I. comes to an end, it still confers a competitive advantage for those health plans that can scale its use. But now is the time to move. Envision the role A.I. will play in your organization in the years to come and develop a strategy roadmap to invest in and leverage A.I. assets.

It pays to keep in mind that, while A.I. can offer much needed technology advantages to health plans, it can’t solve all payment integrity challenges on its own. Ensure your health plan has the best chance to realize these benefits now and into the future. You can and should deeply question your technology vendor and demand specifics around their solution’s A.I. capabilities.

Health payers will need to see all the moving parts of their tech ecosystem, including real-time metrics on advanced healthcare technology performance, in order to prove its value even if A.I. capabilities are touted. Increasing visibility across disparate departments, deriving insights from siloed data, realizing cost savings, and augmenting human expertise and productivity are exactly the type of improvements that show A.I. at its best.

Pareo – Powered by A.I.

At this stage, A.I.- powered solutions may be more commonplace than you realize, but the true value offered by artificial intelligence for healthcare varies from vendors to vendor. The most powerful way to harness A.I. capabilities is when they are applied as part of a broader solution, an advantage provided by an integrative platform like Pareo®.

Pareo® offers multiple applications for of A.I. as part of a broader “one-source” system insight platform for health plans and payers. Deep learning powers the fraud, waste and abuse detection and prevention solution that integrates seamlessly with overall payment integrity. With its multi-dimensional view of data, it offers distinct advantages over rules-based tools.

Pareo also leverages artificial intelligence to increase auditor efficiency and effectiveness with clinical audits. It integrates OCR technology to make unstructured data searchable, filterable and sortable. Then, NLP and machine learning applications of A.I. help auditors prioritize cases for review and automatically tag relevant documentation. The solution also generates confidence scores for denials so cost containment leaders can better trust results.

A.I. is a crucial technology for your health plans to adopt or expand upon throughout your organization. Set yourself up for success and start using artificial intelligence now to address the challenges in healthcare brought on by increasingly complex data.

 

THE FUTURE OF FWA IS NOW

Learn more about the ClarisHealth 360-degree solution for total payment integrity and FWA, Pareo Fraud: Case Management and Detection.

ClarisHealth Launches A.I. Powered Healthcare Fraud Detection Solution for Health Plans

ClarisHealth Launches A.I. Powered Healthcare Fraud Detection Solution for Health Plans

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.”

About ClarisHealth

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.

View source version at: https://www.prweb.com/releases/clarishealth_launches_a_i_powered_healthcare_fraud_detection_solution_for_health_plans/prweb17373183.htm

Source: ClarisHealth

Top 10 Reasons Health Plans Choose Pareo

Top 10 Reasons Health Plans Choose Pareo

It’s almost 2020, and forward-thinking health plans have a choice when it comes to total payment integrity solutions.

From smaller regional plans with 100k members to large national health plans with millions of lives covered, Pareo scales to accommodate all needs. Here are the top 10 reasons that health plans choose Pareo:

1. Reduce Administrative Spend

Health plans often seek out Pareo as a total payment integrity solution that eliminates administrative complexity, reducing overall spend. It’s estimated that 10% of all health care spending in the U.S. is wasteful, attributed to administrative costs that would be eliminated by more efficient processes.

The burden of cumbersome, manual admin processes lead MCOs to miss timely provider payments, tightening their provider network and placing an unnecessary burden on patients and providers.

For managed care organizations (MCOs), the cost to coordinate benefits is estimated at 12% of a health plan’s entire spend. ClarisHealth’s solution simplifies and automates workflows, allowing our clients to quickly optimize operations and reduce costs for coordination of benefits.

2. Optimize Relationships with Business Partners

For many health plans, bringing on more business partners to improve recoveries is a top-level goal. However, the inability to see the “bigger picture” makes it extremely difficult for health plans and their business partners to plug in easily or operate at maximum utilization. Pareo is able to optimize relationships with business partners, allowing health plans to grow their recoveries and easily coordinate goals with third-party payment integrity partners.

Pareo is able to benefit both health plans and business partners by offering easier onboarding, real-time feedback, fast turnaround on new concepts, and multi-beneficial sharing of information that’s customized to each business partner. We view our technology as a crucial connection that improves technology capabilities for health plans.

3. Eliminate Work Silos

Work silos are a byproduct of company structures, based on natural development of ideas and workflows within departments. However, it’s widely understood that these silos prevent the overall growth of an organization. The healthcare industry in particular has suffered from data siloing in large part due to manual, inefficient work processes.

As health plans seek to centralize their payment integrity efforts and break down data silos, they turn to Pareo. Our total payment integrity technology supports initiatives that break down silos, such as change management techniques, by culling system-wide data and presenting it through a single portal.

4. Organize Big Data

Data is an integral part of health plan operations, but many organizations struggle with the task of managing so much information. Pareo assists with process digitization, allowing our clients to move beyond spreadsheets and into a more dynamic platform.

When managing data is no longer of primary concern, health plans can move into activities that generate a higher return on their investment. Faster decision making and utilizing predictive analytics (both available with Pareo) can take a standard data report and turn it into actionable insights -- all in real-time.

5. Modernize fraud,  waste and abuse mitigation

Health plans that want a more robust fraud prevention program seek also to address waste and abuse, a holistic approach that keeps a tighter cap on improper payment rates. Our clients use Pareo to …

  • Analyze post-adjudicated and post-pay claims data (useful as the Federal government is starting to look at how health plans do this)
  • Intelligently flag potential waste and abuse claims
  • Automate claims and auditing workflows
  • Introduce the application of AI technology 

Waste and abuse actually outsize fraud, but the terms are perceived as more ambiguous, resulting in the use of limited technology rather than broader solutions. Health plans may mistakenly think they’ve got payment integrity “covered” when they really only have fraud-prevention technology in place. By addressing a health plan’s entire payment integrity continuum, Pareo helps our clients transition more post-pay activities to prevention. 

6. Improve Provider Engagement

As more providers collect payment upfront and more payers look closely at member satisfaction, the intersection between the two has narrowed. Proactive health plans are seeking to improve provider engagement with the understanding that doing so has a direct effect on member satisfaction rates, and they’re choosing Pareo as the technology that supports this.

Keeping your health plan’s providers happy will also keep your members satisfied.

By automating activities, providing access to necessary claims documentation, and removing redundancies, Pareo is able to significantly minimize provider abrasion. We are firm believers in tracking a Net Promoter Score with your health plan’s providers as way of measuring improved engagement.

7. Control Claim Spend

Why settle for 1-2% as the rate of return on claims when you can get up to 10% by using Pareo? Total system visibility is required in order to control claim spend, but without understanding what’s possible, many health plans settle for less.

Overspending is a huge problem in healthcare, accounting for about $1 trillion of total healthcare expenditures in the U.S. With Pareo, you can actively track your spending on claims in real-time, allowing your health plan to quickly correct course. Excessive administrative costs, missed prevention opportunities, and unnecessary services are all causes of overspending. Pareo’s advanced analytics module allows health plans to gain traction on claim spend, improving recoveries and furthering ROI.

8. Access a community

I think by now many of us understand that organizations suffer when information isn’t shared. Health plans are seeking technology solutions that afford them access to shared expertise. While accessing a group of people who are looking for the exact same solutions that you are is incredibly valuable, another perk of being a member of a community of users is reaping the benefits sown by early adopters. Those first movers are often working closely (whether they know it or not) with QA to ensure your software experience is all the better. In addition, first movers can easily become super users and a source of community knowledge for other members.

Numerous health plans — of all different sizes, with different lines of business, etc. — all working within a common platform is a feature of the SaaS model, not an accidental by-product.

True, health plans have not historically unified on matters of business practice. At a time of rapid disruption, it’s helpful to realize that collaborative organizations have proven more effective. Real benefits of collaboration among departments, with other stakeholders and even with other health plans include: reducing administrative costs, fast-tracking innovation, and improving working relationships.

9. Integrate fragmented systems

Disparate data systems are being abandoned, but as API integration becomes the norm, many health plans are learning not all technology is created equal. With the declaration of APIs as the “better” solution for interoperability, health plans will need technology ecosystems that support integration and allow them to connect and visualize data in a meaningful way. 

The ability for a health plan to share data is mandated — and will continue to be closely watched and regulated once the Proposed Rules become final. For many, the ability to meet or exceed interoperability rules brings health plans to a “disrupt or be disrupted” type of choice. 

10. Transition more efforts to prepay

Post-pay concepts in a prepay environment? That’s just a pipe dream for health plans. Or is it? Payment accuracy isn’t a problem that’s going away anytime soon, but pay-and-chase is expensive for health plans to maintain. Leaders are looking for more ways to prevent improper payments from ever occurring but in order to do so, comprehensive insight and management is needed. 

ClarisHealth works with health plans to develop a specific implementation and use plan for Pareo that meets and often exceeds the goals you’ve outlined for your plan. The ability to transition more claims to prepay requires transformative technology solutions that can integrate disparate systems, such as those offered by Pareo. 

Learn More

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

Behind the Curtain: What to expect when you implement Pareo

Behind the Curtain: What to expect when you implement Pareo

Pareo is a unique platform that integrates with other software solutions to provide a comprehensive look at a health plan’s payment integrity processes. Here’s how we approach implementation of enterprise technology.

Just got word that your health plan is adopting Pareo® as a comprehensive payment integrity solution? Here, we pull back the curtain on what all goes into ensuring your health plan and Pareo work together in perfect harmony.

How We (All) Got Here

Our path to Pareo wasn’t all that different than yours. We started with a seemingly-unsolvable problem: How could we get a better view on everything we needed to see in order to effectively manage claims operations? With time, talent and industry expertise we developed a platform designed to transform payment integrity operations and shifted our focus to healthcare technology.

We acknowledge that when you offer folks a solution they’ve never seen before, you have some educating to do. As such, here are some resources from our archives that touch on some of the steps leading to adoption and implementation of Pareo: 

Meet the Team

ClarisHealth has a team of experienced professionals dedicated to ensuring your Pareo implementation is a smooth transition. Leading the pre-Implementation team is Ric Stubblefield, Director of Implementations. Ric has overseen implementation of healthcare Software as a Service (SaaS) solutions like Pareo for nearly a decade, managing large teams of project managers and specialists while also serving as the main point of contact for clients during the process. 

At ClarisHealth, the Implementation team works closely with Product Support to guide clients through each stage of Implementation and ensure a seamless hand-off after the implementation project is complete. Our post-Implementation team lead is Yaw Agyemang, Director of Product Support. Yaw leads a team of product consultants who ensure that the functionality of Pareo meets the needs of our end users. He has decades of healthcare industry experience and has been a key contributor to shaping Pareo into the solution it is today. Yaw’s team serves as the ongoing point of contact for Pareo users. 

Why does this matter? As industry vets, we understand our clients and their frustrations because most of us have either been in your shoes or worked so closely to this industry that we know the long-running pain points you face. Under Ric and Yaw’s leadership, we’ve selected team members that are uniquely devoted to your success: 

    • Problem-solvers with a results-first focus
    • Industry experience
    • Clear communicators
    • Proven methodology with training every step of the way

Pareo Implementation in 7 Steps

Though we cater our implementation process to meet the needs of each individual client, our decades of experience have taught us to follow a seven-step process to guide each implementation project:

Project Kickoff

The Implementation team will review the statement of work (SOW) and develop a communication plan that establishes meeting and reporting cadences. At this stage, we will review the major components of each project and identify key deliverables. Known challenges are also acknowledged as our team prepares for discovery. 

Discovery

VP of Operations Kevin Jordan works closely with our Implementation teams in a discovery process that reviews workflows, user access (including role definition), reporting needs and process exceptions. During this phase, we also conduct a technical discovery. This includes the review of data file layouts, frequency of delivery and reviewing claim system integration requirements and file formats. This includes identifying vendor submission file formats.

Data Gathering

We conduct data gathering operations throughout the project. Initially, this phase consists of defining roles and rights for each user. Our team will also gather vendor details and load order, creating and reviewing sample reports. Data definitions are created as well as integration file formats. This is the stage when we begin communication with vendors and initiate training.

Configuration and Data Transfer

Configuration is dependant on the process workflows defined in the discovery phase, for both test and production environments. Clients can expect their reporting and dashboards to be created during this phase, configured and loaded into Pareo for review. As such, historical claim, provider and member data files are loaded and mapped. Custom fields are also tested and reviewed in this phase.

Testing

In the testing phase, we use sample vendor files and test all loading logic, review validation workflows and test claim system integration. Reports and dashboards, reviewed in the previous phase, are evaluated closely here for accuracy. Also, all user roles are security tested in this phase to ensure accurate access has been granted.

Client Sign-Off

In the test environment, once approved, the client signs off on the work that has been done. This triggers the creation of the production environment. Once the production environment is created, data migration occurs after which a final review is conducted before final sign-off in productions. 

Go-Live

The last leg of the process! During go-live, health plan and vendor production files are submitted into Pareo. Any issues found at this stage are actively managed by the Implementation team. Once resolved and when all parties agree that go-live is a success, the client is transitioned to the ClarisHealth customer success team! 

Average implementation projects last six to nine months, though this timeframe very much depends on a client’s needs and the SOW. As we implement Pareo at your organization, we have structured our process to include best practices allowing us to act in a secondary role as a software implementation consultant. This approach allows us to offer greater value to clients, who rely on us to lead them through this transition. 

This consultative mindset continues post-implementation. We have internal teams solely focused on developing education and other training tools and delivering those to clients in an ongoing manner to support engagement and utilization of Pareo. 

NOW'S THE TIME FOR TOTAL PAYMENT INTEGRITY

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

Managing Medical Record Requests a problem? We’ve got the solution.

Managing Medical Record Requests a problem? We’ve got the solution.

How to manage medical record retrieval processes with multiple clinical audit vendors.

Is your health plan missing out on the potential of having multiple clinical audit vendors because you’re concerned about overlapping medical record requests? That uncoordinated approach to medical records retrieval is unnecessary in the modern age of vendor coordination and provider communications. 

For health plans that are ready to maximize their returns, improve recoveries and avoid the abrasion created by redundant medical record retrieval processes, Pareo® is your answer. Pareo is a comprehensive payment integrity solution that works by making data more accessible, connecting it to multiple stakeholders and managing real-time communications (including those related to the claims process and associated with technology vendors). With these efficiencies in place, health plans are able to maximize their recoveries by adding clinical audit vendors. Data is no longer siloed — it can be seen, used and leveraged by health plans. That’s the power of Pareo. 

Overlapping Medical Record Requests Begone

Suppose your health plan were to prioritize adding clinical audit vendors without a broader management tool in place. One of the very real side effects of this practice is overlapping medical record requests. It’s frustrating for everyone, especially providers who seek to prioritize patient care over cumbersome administrative processes. 

In instances where health plans have a lot to lose (recoveries, valuable providers, plan members), clear communication is crucial to success. We understand that our clients need to do more than just talk at stakeholders; they need to intelligently coordinate with vendors, providers and members in a streamlined but meaningful way. 

Unfortunately, some of the payers we speak with feel forced into an impossible decision: improve provider relationships OR recoveries. This approach, while understandable, is unnecessary. What if you could do both? What if expanding recoveries through adding vendors — a smart strategy for scaling health plan payment integrity operations — wasn’t stressful on providers? 

Harmony: Vendor Coordination + Provider Communications

By eliminating the fear of overlapping medical record requests, you are free to stack the best vendors to your advantage. Directing vendors to laser focus on their area of expertise creates more potential for finding anomalies; for example, having vendors concentrate on a line of business (e.g. Medicare Advantage, Medicaid, commercial). Data tells us that any time a health plan adds a vendor in a multi-pass capacity, their ability to increase recoveries improves dramatically. 

But don’t leave providers out of the loop. Health plans often run a planned series of audits that parallel those that a provider performs. With Pareo, each party can be on the same page about these audits; knowledge and understanding of them beforehand can minimize redundancies, says Healthcare Finance.  But as we all know, it’s not as simple as straightforward communication between a payer and a provider. Vendors are an important component as they rely on data to deliver results. 

Enter Pareo Clinical.

Pareo Clinical: Eliminates Risk Around Medical Record Requests + Retrievals

Tackle risk, reduce inefficiencies, increase nurse auditor throughput, improve your net promoter score (NPS) and increase recoveries with Pareo Clinical. Our solution provides gates and custom logic that streamline the medical records retrieval process to coordinate with vendors, eliminate duplicate requests and auto-route submissions to the appropriate auditor with smart tagging so nothing gets overlooked. 

To enhance communication, our solution creates a unilateral or bi-lateral portal of communication for our clients that allows them to not only communicate with vendors but with another very valuable player: providers. We understand that in today’s IT ecosystem, a true solution has to “speak” with multiple stakeholders in a way that removes redundant, wasteful processes. 

Those communications streamline activities that can be automated. But perhaps just as important, Pareo allows for sophisticated coordination between all stakeholders. With our technology, even pending requests — days outstanding, notes on interactions, etc. — can be tracked to prompt proper follow-up strategies. These efficiencies mean more clinical audit vendors and less abrasion with providers. In today’s world where health plans are being asked to do more with less, a scalable, comprehensive solution is the strongest way forward. 

Learn more about how Pareo supports health plans, providers and third-party vendors

Talk to ClarisHealth about how Pareo®advanced payment integrity technology is helping health plans stride confidently into an uncertain future.