Will AI finally make good on its promise to healthcare?

Will AI finally make good on its promise to healthcare?

Artificial Intelligence continues to be a much-hyped “trend” for healthcare technology but adoption lags. Here’s what AI is — and isn’t — and why this may be the decade it takes hold for health plans.

When IBM Watson, the AI supercomputer created by IBM, won Jeopardy! and then moved on to a career in healthcare (via Watson Health in 2015), the industry was abuzz with possibilities. Sci-fi speculation ran rampant and then fell flat, when in 2017 it was revealed that IBM Watson wasn’t exceeding — or even meeting — expectations. AI capabilities were muddied by the hype, and adoption of the technology continues to be slower than expected. 

However, AI is a powerful force in technology and crucial to disrupting the healthcare industry. And in 2020, AI is poised to improve rapidly (it was recently reported that Google’s AI system was more accurate than experts in finding breast cancer).  Let’s explore what AI is — and isn’t — and why it’s here to stay. But first, a few definitions:

Artificial Intelligence: Intelligence applied to a system with the goal of mirroring human logic and decision-making. AI is utilized for the purpose of successful knowledge acquisition and application, which it prioritizes over accuracy. AI simulates intelligence (the application of knowledge). It is a combination of technologies, comprised of machine learning and predictive analytics.


Machine Learning: An application of AI that allows a system to learn on it’s own. ML learns from data, and it aims to increase accuracy (success is a lesser concern). ML simulates knowledge. Source


Data Mining: Unstructured data that is collected, often for the purposes of data analytics.


Predictive Analytics: 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. Predictive Analytics often implies that a machine has performed the analysis and offered a prediction (rather than a human).

Is 2020 the year for AI?

Experts predicted that AI would grow rapidly in 2019, but adoption waned. Additionally, a growing number of consumers (and regulators) are becoming uncomfortable with “black box” AI. 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 all industries, AI can vary greatly by product and generalized claims can be misleading. In healthcare, relying on AI before explainability has been satisfied is a large risk. Yet, creators of the algorithms that power AI will often refuse to disclose how they work, citing proprietary information.  

The lack of explainable AI is a huge hurdle to applying (and approving) the technology’s use in clinical care settings. For example, when a study showing that AI could interpret risk of patient death based on ECG test results with greater accuracy than physicians, without being able to explain how it did so, doctors expressed amazement — and discomfort. “It’s still unclear what patterns the AI is picking up, which makes some physicians reluctant to use such algorithms.” Furthermore, lawmakers are still grappling with how to regulate the technology, and those outcomes can play a significant role in health tech.

Early adopters in the healthcare payer sector understand the benefits and risks associated with AI all too well, and skepticism of vendor claims of AI is high (and rightly so). However, the value of AI is steadily increasing, and AI compute has been doubling every three and a half months. In fact, 2020 was a remarkable year for the advanced technology. The AI Index 2019 Annual Report calls out the following technical performance achievements: 

  • In just a year and a half, large image classification systems are training much faster on cloud infrastructure, down to 88 seconds in mid-2019 from three hours in late 2017. Costs to train these systems have also fallen.
  • Progress on natural-language processing classification tasks is “remarkably rapid,” though performance on NLP tasks that require reasoning has not kept up

If investment dollars are any indication, AI technology will continue to boom. Last year, global private investment dollars in AI topped $70 billion: 6.1% of those investment dollars were attributed to drug, cancer and therapy while 3.9% was given to fraud detection and finance. 

How AI is Applied to Healthcare Technology

AI is expected to permeate every facet of healthcare, with annual spending on advanced technology estimated to be more than $34 billion in 2025. But AI is not a solution in and of itself; it’s an application of various methodologies, and this causes some confusion. The current applications of AI in healthcare are narrow and highly functional, especially given that the quality of the technology itself can vary based on the vendor.  

Some current applications of AI for health plans include: 

Fraud, waste and abuse solutions

Value-based care initiatives

Claims Management

Coordination of Benefits

Predictive Analytics

Potential applications for advanced technology are much broader and include increased efficiencies and improved patient outcomes. Surveyed physicians have reported that AI is already improving the time they spent with patients, and 78% of healthcare business leaders say that the advanced technology “has helped drive workflow improvements, streamlining operational and administrative activities and delivering significant efficiencies toward transforming the future of healthcare.” Yet, explainability may hamper some AI adoption in the coming year. 

“Differentiating on price isn’t going to be the way to win in healthcare; differentiating on experience will be.”

Heather Cox, Humana’s chief digital health and analytics officer, on why Humana is investing in AI to enhance patient experience

In the coming year, healthcare payers will 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 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. 

Health payers will need to see all the moving parts of their tech ecosystem, including real-time metrics on vendor performance, in order to be able to see vendor lift, even if AI capabilities are touted. Increasing visibility across disparate departments and retrieving data from silos are exactly the type of improvements that show AI at its best. 

How Your Health Plan Can Utilize AI

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. While AI can offer much-needed technology advantages to health plans, it isn’t capable of solving all payment integrity problems on its own. If a technology vendor is touting its AI capabilities, the solution should be more than a “black box of mystery.” You can and should deeply question and demand specific capabilities in regards to AI from a technology vendor. 

That said, AI is a crucial technology for health plans to adopt or expand upon within their organization. The massive amounts of data inherent in healthcare systems have presented a problem for the industry as a whole. With AI, data can be mined and utilized to harvest useful insights. Historical data can be loaded into the system and utilized alongside real-time data for predictive analytics. Pareo® offers multiple applications for AI as part of a broader “one-source” system insight platform for health plans and payers.

Despite IBM Watson falling short of expectations, AI technology will only continue to improve and the past year has proved that. At this stage, AI technologies may be more commonplace than you realize, but the true abilities of artificial intelligence vary between technology vendors. The most powerful way to harness AI capabilities is when they are applied as part of a broader solution, an advantage provided by an integrative platform like Pareo®

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

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Will AI finally make good on its promise to healthcare?

Will AI finally make good on its promise to healthcare?

Artificial Intelligence continues to be a much-hyped “trend” for healthcare technology but adoption lags. Here’s what AI is — and isn’t — and why this may be the decade it takes hold for health plans. When IBM Watson, the AI supercomputer created by IBM, won Jeopardy!...

2020 Vision: A look at Healthcare Payer Technology Trends

2020 Vision: A look at Healthcare Payer Technology Trends

Reviewing  the drivers, restraints, challenges and opportunities for healthcare payer technology in 2020. You’ve made plans, met for countless hours to strategize on the coming year and finally it’s here: 2020. A new year and a new decade promise big changes for the...

2020 Vision: A look at Healthcare Payer Technology Trends

2020 Vision: A look at Healthcare Payer Technology Trends

Reviewing  the drivers, restraints, challenges and opportunities for healthcare payer technology in 2020.

You’ve made plans, met for countless hours to strategize on the coming year and finally it’s here: 2020. A new year and a new decade promise big changes for the industry. And much like we did last year, we are looking at industry drivers, restraints, challenges and opportunities to ensure payers are on the right track for the coming year. 

We didn’t have to look far. Thanks to 2019, much of the writing is on the wall regarding expectations of health plans for 2020 and beyond. We’ve followed these trends throughout the year. Look for our guide below to explore articles we’ve published on key topics impacting health plans. 

Drivers: Top Motivators for Health Plans in 2020

Last year, we predicted that “2019 will be the year that health organizations will need to make real upgrades in technology if they haven’t already, or face issues meeting government regulations.” We didn’t know then how prescient that statement would be. By February, CMS and HHS had issued the proposed Final Rules (expected to be final in early 2020) to promote freer sharing of healthcare data. This initiative is driven in part by value-based care directives, the need to reduce provider abrasion, and the emergence of industry disruptors. The far-reaching implications dominated the news cycle throughout the year and will continue to do so in 2020. 

“2019 was a year of acceleration in digital health with several foundational advancements.”


The ultimate goal of technology is to break down barriers and allow information to empower a better healthcare system. This is termed “cognitive collaboration.” With interoperability and information blocking as a focus, health plans will naturally evolve to start questioning any process within their organization that inhibits information sharing.

Health plans understand with greater clarity now that their members, who are tasked with owning their own healthcare experience, will expect their relationship with their health payer to be frictionless and intuitive. This expectation (and the risk that not meeting consumer demand will open payers up to disruption) will lead health plans down a path that, if navigated correctly, can open up numerous opportunities to improve claims recovery processes and program integrity efforts. As a result, plans will look more closely at social determinants of health and healthcare data as primary drivers of consumer experience. 

Health plan workforces are and will continue to be impacted by technology as well. Lean as the industry may seem, health plans are adapting to the “do more with less” credo unofficially adopted by all healthcare stakeholders. As payers start to experience the big picture benefits of advanced technology,  health plans will be able to work towards becoming more proactive and less reactive. 

To that end, in 2020 health plans will be tasked with separating the wheat from the chaff when it comes to technology claims by third-party vendors, particularly firms looking to leverage experience with other industries into similar successes in the healthcare sector. Understanding that technology can help rapidly improve ROI on the claims recovery process, health plans will need to become more sophisticated consumers of tech products and solutions in the coming year. 

With great change comes the need for health plans to keep up with more sophisticated schemes and improper payment incidences. The SIU, which often operates as a disparate island within health plans, will feel the pressure to become more integrated with other departments. Many health plans have invested heavily in technology to combat fraud, waste and abuse but are growing weary of the lack of sophistication found in most solutions on the market. But health plan departments are all realizing that in every case, advanced technology is only as good as the data. These struggles will unveil a new focus on the need for better data collection practices across the healthcare continuum. 

You may also enjoy reading:

Information Blocking Rule: Are we ready?

What makes Value-Based care work for health plans? 

Making outsourced vendors work better for PI.

SDOH coverage, less complexity. Here’s how. 

Centralize efforts with API integration.

Should Medicare-for-All be feared by health plans?

Planning for the unknown: A guide for health plans making strategic plans for 2020.

Restraints: Navigating the Roadblocks Health Plans Face

What’s information blocking, exactly? Many health plans, industry experts and health organizations are asking this as the proposed Final Rules move through final stages. The Rules, which many feel did not properly define information blocking, were not revised despite broad calls for them to be. Still, a decent portion of surveyed healthcare executives (43%) have indicated they plan to go above and beyond any interoperability and information blocking measures put in place by the Final Rules. The majority of health plans, however, will have to react quickly to interpret these terms, according to a survey. 

It’s an election year and federally regulated changes to the healthcare system will be mired in politics in 2020. Health plans will have to plan for all outcomes. One factor that transcends partisan politics, however, is transparency. Consumer-driven and value-based care is a certainty and transparency (fueled by interoperability) will be the aim. This transition has proven difficult for health plans due to complex regulatory environments, data security requirements, shortages in skilled workers, and struggles to shift old processes into new practices at a speedy rate. 

Dealing with large amounts of patient data makes health plans a prime target for security breaches. Health plans are moving methodically with technology adoption to mitigate risks, thereby delaying the realization of benefits from improved technology. Additionally, health plans will have to overcome learning curves, fear of change and other employee challenges as they navigate business and look for increased returns. Plans face challenges and limitations when it comes to combating fraud, waste and abuse due to a lack of relational data on the most-likely group to commit FWA: providers. 

Challenges: Factors for 2020

Let’s look at the specific factors that will challenge health plans in 2020: 

  • Proposed Final Rules
    • The proposed rules on information blocking and interoperability were submitted to the Office of Management and Budget at the end of October. OMB typically has 90 days to review a rule and make final, but they did not identify a deadline. The rule is expected to go into effect in 2020 but many questions remain. 
  • Big Tech Cynicism
    • Big Tech (think Google, Apple, Amazon) have circled around healthcare in recent years, but insiders doubt the technology giants can truly solve healthcare’s biggest problems. Robert Pearl, MD, former CEO of the Permanente Medical Group, outlines some of the biggest hurdles these outsiders face in healthcare:
      • Deciphering consumer wants versus medical needs
      • Medical liability
      • Growing data ownership and privacy issues
  • ACA
    • Short Term Health Plans were made legal in 2019, and according to CMS they can be used for 12 months and renewed for up to 3 years
    • Consumers have more options
    • Risk adjustments payment program implemented under ACA was upheld in court at the end of 2019. Reuters reports that the “decision by the 10th U.S. Circuit Court of Appeals in Denver is a victory for insurers that feared the Feb. 2018 lower court ruling and payments suspension could drive up premium costs and cause market turmoil.” 
  • Value-Based Care
    • CMS released their Value-Based Purchasing Program results for 2020, stating “in FY 2020, more hospitals will receive positive payment adjustments than will receive negative payment adjustments.” This is a rise of about 5%, according to FierceHealthcare which reported that 55% of hospitals got a payment bonus in 2019. CMS is looking to boost value-based care adoption rates which waned in 2019. Health plans look to diversify benefits and meet SDOH tenets as care perspectives shift to whole patient health. 
  • Mandated Transparency 
    • A large push to promote healthcare cost transparency, termed the “price transparency rule” which was released in November of 2019 via executive order has met with roadblocks including a lawsuit questioning the validity of requiring hospitals to disclose negotiated prices with insurers, which would take effect in 2021. The other component of the rule, if finalized, would “give patients access to their insurers’ cost-sharing liability and disclose the insurers’ negotiated rates for in-network providers and allowed amounts paid for out-of-network physicians,” reports Medical Economics
  • Election Year
    • Political candidates are running on healthcare reform, with more liberal Democratic candidates promoting “Medicare for All.” Big changes are unlikely during an election year, but payers will have to buckle up for what could be historic overhauls to the healthcare system in coming years. 

Opportunities: Chances to Excel in 2020

Health plans have the opportunity to be ahead of the curve by making strategic investments in change, particularly surrounding transparency. Integrative technology and shifts in program integrity approaches will allow payers to continue to gain ground and focus on proactive efforts, particularly when it comes to claims recovery and payment integrity.  Health plans may breathe a sigh of relief that the “Cadillac tax” was repealed, which was slated to take effect in 2022 after multiple delays. 

Payers have caught on to the fact that providing improved member services is a differentiator in a consumer-driven market. By addressing all 6 social determinants of health, plans can offer broader benefits with perceived higher values (even if costs are lower). CMS has made it easier for health plans to offer supplemental benefits, another incentive for offering them. Digital health adoption continues to grow with some plans even covering personal health devices and offering increased telehealth capabilities. 

“According to Deloitte’s 2018 “Global State of AI in the Enterprise, 2nd Edition” survey, 80% of the respondents said their AI investments had already led to ROIs of 10% or more.”


Technology advancements continue, as API becomes more accepted and blockchain capabilities improve. Plans can leverage the mountains of data they collect through improved data analytics technology, reducing time to reports and empowering real-time decision making. Through secure integrations, data sharing could be a hurdle that health plans finally surpass. Cognitive collaboration capabilities will emerge for health plans if they utilize the right technology solutions and empower users to break down barriers within their organization to drive efficiencies and improve the care continuum. 

Partner to Make 2020 the Best Year Yet

Talk to ClarisHealth about how Pareo® can improve your health plan’s payment integrity processes -- no matter what the future brings.

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. 

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

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Will AI finally make good on its promise to healthcare?

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Artificial Intelligence continues to be a much-hyped “trend” for healthcare technology but adoption lags. Here’s what AI is — and isn’t — and why this may be the decade it takes hold for health plans. When IBM Watson, the AI supercomputer created by IBM, won Jeopardy!...

2020 Vision: A look at Healthcare Payer Technology Trends

2020 Vision: A look at Healthcare Payer Technology Trends

Reviewing  the drivers, restraints, challenges and opportunities for healthcare payer technology in 2020. You’ve made plans, met for countless hours to strategize on the coming year and finally it’s here: 2020. A new year and a new decade promise big changes for the...

Your FWA solution may not be as modern as you think.

Your FWA solution may not be as modern as you think.

The package may have changed, but the truth is most FWA solutions are still relying on legacy technology. 3 ways to spot the difference.

To prepare for the advancing disruptions to healthcare, most plans we speak with have made some progress towards digital modernization. Often, they’re starting with evaluating their current technology vendors, except for one glaring oversight: fraud, waste and abuse solutions. Did you know, those on the market today are by and large relying on 30 to 40 year old technology? Even many “new” solutions are old products dressed up in new packaging. 

While it can be comfortable to use products we are most familiar with, the problem is, the way we’ve always done things just won’t cut it anymore. It’s very possible that with each passing year, your tried and true technology isn’t quite so effective. Recent advancements in automation and predictive analytics have yielded modern FWA solutions that promote transparency and integration with other systems. 

Got a hunch the FWA solution you’re using may not be as modern as it should be? Get ready to evaluate the evidence for the three big signs of outdated technology. 

1. Reporting Struggles

Your health plan’s FWA solution may be legacy if… it relies solely on rules-based reports. While rules-based reporting is foundational functionality that is still useful, it only addresses known schemes. Fraudsters are changing up their schemes more often than what legacy solutions can keep up with, meaning this outdated approach will leave health plans in a precarious place (and do you really need to combat more false positives?). 

Rules-based reporting is not multi-dimensional and this impairs an investigator’s ability to ascertain legitimate leads. What’s more, some algorithms are actually rules-based which holds them back from being the robust solution so desperately needed in this industry. “Traditional analytics solutions built on relational databases aren’t up to the task,” writes Fierce Health Payer. That’s because fraud schemes are growing increasingly complex, and flat views of them will make legacy FWA solutions a drain on the SIU’s limited resources.

Another reporting issue? The “pull” approach. If your reporting lags and is centered around knowing the right questions to ask, you aren’t accessing the bigger picture. In comparison to a robust data analytics system, pulling reports does not prioritize issues. “Payers should look for platforms that visualize data in an informative way, develop insights using financial big data, and support predictive analytics capabilities,” writes Health Payer Intelligence.

2. Too Little Information on Providers

Lacking visibility into providers? You’re not alone, and it’s yet another sign of older FWA technology. The SIU is by and large missing the ability to efficiently and effectively access provider details, which may range from a particular provider’s associated practices to a lack of visibility into provider education (and no way to measure efficacy of that education). 

When investigators lack visibility into provider data, efforts to obtain that information come at a cost. And while manually communicating to determine provider details or check in on remediation programs, health plans run the risk of a greater cost in the form of provider abrasion. While most fraud schemes may happen at the provider level, very few providers are fraudsters. Communications from the SIU have to be considerably more precise and streamlined than what legacy technologies may afford.

According to NHCAA, “the majority of healthcare fraud is committed by a very small minority of dishonest health care providers.”

Research by the Government Accountability Office (GAO) shows the following trends in provider fraud schemes: 

  • Falsifying claims or diagnoses
  • Participating in illegal referrals or kickbacks
  • Prescribing unnecessary medications to patients
  • Upcoding for expensive, medically unwarranted services

3. Limited to Pay-and-Chase

Health plans are weakened without the proper tools to navigate away from pay-and-chase and towards prevention. But the standard approach to FWA is chasing down improper payments, rather than preventing them. If your current FWA solution does not allow you to effectively detect the risk of an improper payment before that claim is paid, you’re likely using a legacy system.  

Now that the technology is improving, more sophisticated approaches are available. These preventive solutions tend to rely on predictive modeling, but be warned the quality can vary greatly. If a vendor you are considering uses buzzwords like “AI” and “machine-learning” to describe their product functionality, you should know these terms are often used incorrectly. 

It behooves SIU and Compliance teams to drill down into vendor claims of advanced technology to see how predictive capabilities function. Are they dynamic and do they rely on good data? Are they using the right set of metrics? And perhaps more importantly, can these advanced technologies integrate intelligently with a plan’s overall payment integrity processes? Because more and more, effective FWA detection is reliant on more than the SIU. 

So your FWA solution is outdated, now what? 

If you think your FWA solution is no longer up to the task, it may be helpful to focus first on what your organization needs from a technology provider. A true FWA solution is one that gives investigators the tools they need to separate the signal from the noise, quickly and effectively. Advanced integrative technology that provides broader access to real-time data will allow your health plan to modernize the SIU. 

Partner to Make 2020 the Best Year Yet

Talk to ClarisHealth about how Pareo® can improve your health plan’s payment integrity processes -- no matter what the future brings.

Where does your health plan reside on the payment integrity continuum?

Where does your health plan reside on the payment integrity continuum?

Take this interactive self-assessment to determine how much progress your health plan has made towards modern digital transformation.

The goal for every future-looking health plan is to transition payment integrity efforts from predominantly external post-pay, to a healthy mix of prepay and post-pay both internally and externally. The current status for many health plans is highly reactive in nature, heavily dependent on external vendors, and losing $0.25 on every dollar recovered post-pay as a result. 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.

The Payment Integrity Continuum

As health plans evolve to effectively manage payment integrity, efforts to manage it become two-prong: centralize and shift. Plans further along in the evolution of payment integrity  realize that PI is a comprehensive activity. Breaking down data silos to centralize efforts is the first phase. Next, PI efforts shift to strategic, more proactive functions within the health plan. 

Self-Assessment: Where does your health plan fall on the PI Continuum?

Take this self-assessment tool to look strategically at key elements of your payment integrity activity and evaluate where your health plan falls along the PI continuum.  

Your Results: Steps Along the Continuum

All payment integrity efforts wrap around the specific needs of a health plan. But certain core functions exist and, in our experience, evolve over time to form a PI continuum that aims for integrative, comprehensive functionality within a health plan. Add up your points from your answers above, and let’s see how much progress your health plan has made and what your organization can do next to keep progressing.

Score Total Less than 7: Needs improvement

At this stage, we usually see a health plan with claim edits build into an adjudication system but limited post-pay identification efforts. Next steps:

  1. You probably aren’t where you want to be regarding the latest technology, and that’s okay. Start small and strategically work your way towards catching up to your goals.
  2. If you haven’t yet, consider adding a first-pass third-party service vendor to your payment integrity efforts. Here are some tips for choosing the right supplier partners.

Score Total 7 – 9: Making progress, slowly

With expanded post-pay activity covered by first-pass, third-party vendors for major services (COB, data mining, clinical audit) complementing internal post-pay efforts, you’re moving in the right direction. Next steps: 

  1. Time to level up your efforts to combat fraud, waste and abuse. Start here.
  2. Advanced technology will help you reach the next level of payment integrity, quicker, but it can feel disorienting to update your existing processes. Here’s our guide to making those internal discussions more fruitful.

Score Total 10-12: Headed in the right direction

By expanding post-pay activity with additional vendors, leveraging vendors as R&D to expand internal post-pay efforts to optimize spend, and introducing FWA technology, you’ve already made a lot of progress. But, you still have too many systems to manage in PI and know there’s more to be done. Next steps:

  1. Ensure you’re making the most of your payment integrity vendor relationships.
  2. If your organization’s PI efforts are spread across multiple departments and stakeholders (a common situation), you can address that structurally by creating a centralized payment integrity department.
  3. Progress of this level can be uncomfortable. As an agent of change, you can help lead your organization into the future. 

Score Total 13-15: Gaining on it, but there’s still room to improve

At this level, you’re probably starting to feel pretty comfortable, introducing a third-party post-adjudication prepay vendor to complement post-pay and FWA efforts and reducing the number of disparate solutions you use to manage payment integrity. Next steps:

  1. Make your first moves to transition claims recovery to prepay.
  2. As your organization increases in sophistication, an integrated advanced technology solution will support those efforts — but only if it’s successfully adopted by key stakeholders.

Score Total 16-18: Your PI approach is close to being proactive

Almost there! By expanding post-adjudication prepay with internal prepay operations in advance of third-party solutions and continuing to round out post-pay activity, your digital transformation is almost complete. Next steps:

  1. Are you missing any opportunities to maximize your recoveries?
  2. Freely and securely exchanging data with services vendors, providers and best-in-breed technology solutions will secure your competitive advantage.

    Score Total 19+: You’ve achieved a strategic, proactive PI management solution

    Congratulations! At this level, you have all lines of business addressed pre- and post-pay with solutions in place to continuously evaluate and move post-pay identifications internally and ultimately to avoidance. As a result, you’re cost avoiding in excess of 30% of overall plan savings. 

    Bottom Line

    Wish your health plan was scoring a little higher on this assessment? Moving your health plan further along the payment integrity continuum with existing resources and processes is almost impossible. You aren’t alone and help is available. 

    As one of our clients put it, “Our vision for payment integrity is to move from a predominant outsource to a predominant insource business model. It is a bold strategy, and we needed an equally bold and innovative partner. We explored many options, including an internal build, until we were introduced to ClarisHealth and Pareo. After the first demonstration of Pareo, we knew that it had tremendous potential to serve as the foundational payment integrity hub to realize our vision.”

    Partner to Make 2020 the Best Year Yet

    Talk to ClarisHealth about how Pareo® can improve your health plan’s payment integrity processes -- no matter what the future brings.

    Tracking the Information Blocking Rule: It’s nearly final, but is the healthcare industry ready?

    Tracking the Information Blocking Rule: It’s nearly final, but is the healthcare industry ready?

    Despite public concern, the final rule is moving forward. Meanwhile, a recent survey says only 18% of healthcare execs understand the seismic implications.

    Both the Information Blocking Rule and the Interoperability Rule (collectively referred to as the Proposed Rules) have been pushed to the final phase: a review by the OMB. This advancement of rules aimed to ease data sharing underscores HHS’s interest in improving interoperability without further delay, especially when it comes to the Information Blocking Rule. ONC’s proposed rule has undergone significant criticism by key industry players, but rather than being reviewed and revised, the rule was moved forward to the final stages. 

    A recent survey by Deloitte indicates that a significant portion (43%) of health plans are well-prepared to meet or even exceed the parameters set forth in the final rule, according to the CTOs and CIOs surveyed. Healthcare executives in a separate survey, however, tell a different story: Only 18% of those surveyed in this study say they understand the implications of the Proposed Rules. Most (65%) report only being vaguely familiar with the set of data sharing rules. This is a problem because the Proposed Rules are sure to have seismic implications on the industry. 

    As the rules move to their final phase, we will evaluate the concerns raised by the public comment period and the continued efforts of large healthcare stakeholders for clarification on the proposed Information Blocking Rule. We will also look at the logistics of implementing these rules, asking how our industry may – or may not be – well-prepared to tackle interoperability once and for all. 

    ONC’s Information Blocking Rule Raises “Significant” Concerns

    Let’s start with what we can all agree on: the goal of seamless data sharing is a noble one. Nearly all stakeholders understand that patients need better access to their data. In this increasingly digital age, rules must evolve accordingly to further define a patient’s right to access their medical data. But for some major healthcare industry experts and organizations, the progression of the Proposed Rules to final review is where the rubber meets the road. In particular, many feel ONC’s nearly final Information Blocking Rule doesn’t do enough to define important data sharing elements (specifically, electronic health records lack a standard definition). 

    In addition, strong concerns have been raised surrounding data privacy over open API connections. Patient medical data is incredibly valuable, say experts, and many agree that patients should have the ability to control when and where their data is used. Experts worry that if patient data is commodified (for example, by third parties), it could result in unintended consequences for the patient. To these experts, a lack of insight into when and where patient data may be used (and who controls those rights) is a major oversight of the Proposed Final Rules. Read more about how API connections improve data sharing here.

    “AMA is calling for controls to be instituted that establish transparency as to how health information is being used, who is using it, and how to prevent the profiteering of patients’ data.”


    What's on the table: Two Rules, Same Goals

    Both ONC and CMS issued proposed rules that aim to tackle the complex problem of data sharing. Though used interchangeably and collectively at times, these are two separate rules. Here’s a look at each one.

    Proposed Information Blocking Rule

    • Released by: ONC in February 2019
    • Status: Under OMB Review. Anticipated final release this year.
    • Has been criticized for being overly broad and administratively complex

    Proposed Interoperability Rule

    • Released by: CMS in February 2019
    • Status: Under OMB Review as a “long-term action item” scheduled to be finalized no later than March 2022

    These rules are collectively termed “the Proposed Rules” and were issued by offices under HHS as part of a broader goal to improve patient access to health data

    The proposed implementation times – some as soon as January 1, 2020 – have also been called out by critics. Rapid adoption is a risk, particularly when awareness and understanding of the rules is relatively low. Groups have called on ONC and CMS to delay implementation and stagger rule deadlines. If this does not occur, the Proposed Rules as currently written will result in overlapping deadlines, which “creates layers of complex requirements for both providers and vendors,” says Mari Svaickis, Vice President of Federal Affairs for the College of Healthcare Information Management Executives (CHIME).  Additionally, the Information Blocking Rule will require EHR and health IT vendors to overhaul products, creating a “substantial industry shift,” according to Svaickis. It is unclear whether or not OMB will address implementation times in their final review. 

    The Health IT Advisory Committee (HITAC) has called on ONC to address specific concerns surrounding the proposed Information Blocking Rule. HITAC, a product of the 21st Century Cures Act, regularly recommends policies to ONC. In addition to data privacy and implementation concerns, the group made other recommendations to ONC in order to ease the burden of the proposed Information Blocking Rule on providers and vendors. Their recommendations are threefold:

    1. Create a new version of the health IT certification (versus updating the 2015 certification)
    2. Better define some of the terms of the rule itself
    3. Ease the penalty for stakeholders found to be in violation of the rule, currently written as $1 million per instance of information blocking

    Supporters Say Benefits Outweigh Risk

    The goal of providing patients greater access to data aligns perfectly with some organizations, particularly those who feel health plans are able to shoulder the interoperability burden. Health plans have made progress towards addressing interoperability already, with increasing focus on API integration (only 3% of health plans surveyed don’t use API). 

    AMGA President and CEO Jerry Penso, M.D. wrote, “Access to claims data from all payers has been a longstanding priority for AMGA and its members. CMS’ latest initiatives support AMGA’s work by allowing providers to access Medicare claims data. If successful, CMS’ initiatives should inspire commercial insurers to follow suit in data sharing, a crucial step in delivering the most effective care for patients and improving health outcomes.” Though he was specifically referring to another data-sharing initiative, CMS’ “Data at the Point of Care (DPC)” pilot, the implication is that AMGA supports all of CMS’ interoperability rules. 

    Where to from here?

    The concerns are on the table, and the rules appear to be moving forward anyway. Detractors are likely still on guard from the rollout of previous rules, namely what was previously called “Meaningful Use” of electronic health records, which fell short of delivering on its promises. Just over 40% of health plans say they are already addressing interoperability as positioned in the Proposed Rules. But that still leaves 60% of health plans in limbo. 

    ClarisHealth has been tracking the Proposed Rules closely over the course of this year. For more on the topic, please see the following articles:

    As a provider of comprehensive technology, ClarisHealth is well-versed in supporting strategic interoperability initiatives at health plans of all sizes. We work with vendors, providers and health plans to make total interoperability possible by utilizing our technology solution, Pareo. Health plans aren’t meant to work in silos. Find a partner that can help. Reach out to ClarisHealth today to begin a conversation about how best to prepare your plan and its vendors for adhering to the proposed rules.

    Partner to Make 2020 the Best Year Yet

    Talk to ClarisHealth about how Pareo® can improve your health plan’s payment integrity processes -- no matter what the future brings.