An Aggressive Plan to Move your Claims Recovery to Prepay Status

An Aggressive Plan to Move your Claims Recovery to Prepay Status

Transitioning more payment integrity operations to internal prepay is more than just a pipe dream for health plans

Transitioning prepay. It’s the holy grail for health plans — and viewed as equally unattainable. And, in the not-so-distant past, this viewpoint would have been correct. But now, with the assistance of innovative technologies, health plans can take an aggressive approach to transitioning claims recovery to an internal prepay model. Here’s a look at the challenge of transitioning to prepay, the solution we propose, and why your health plan can’t continue the business-as-usual efforts in this area. 

 

The “Challenge”

Historically, health plans applying post-pay concepts in a prepay environment have been mutually exclusive ideas

In today’s market, it’s essential for health plans to get a handle on payment accuracy. But, without the proper technology tools in place, it’s difficult for payers (and other healthcare stakeholders) to gain true visibility into their operations. In the case of third-party technology suppliers, who rely on their partners to perform at peak level, these murky waters may prove especially hard to navigate. 

Without comprehensive insight and management, it is very difficult for payers to move the needle on claims recovery. Especially when attempting to shift claims from post-pay to prepay, though doing so promises improved efficiencies and higher rates of return for health plans. We see two common barriers to making this shift:

  1. Even if your third-party vendors possess the kind of technology that would enable you to move more claims to prepay resolution, health plans have no ability to store the most successful concepts and apply advanced analytics prepay. 
  2. Even if you do have insights, limited data analytics resources prevent you from taking full advantage of advanced technology.

You may know that some health plans have been able to shift claims recovery efforts to internal prepay activities, but do you fully understand how? In part, successful plans achieve this by breaking down data barriers. With the right solution in place, payers can actually overcome the limitations that poor data visibility place on them. 

 

Why Prepay is an Urgent Concern

Health plans need the efficiencies that comprehensive payment accuracy technology brings, and prepay is an opportunity to make quick strides. 

We get it. You have a laundry list of to-do’s, all vying for top priority. Digital-first strategy, member experience improvements, optimizing costs and outcomes — these are all important goals. But, it could be that a focus on claims recovery gives your health plan the breathing room it needs for these significant investments. And as professional program integrity problem solvers, we think a shift to prepay is a valuable opportunity for health plans looking to gain traction on aggressive payment accuracy targets. 

We aren’t alone in suggesting a technology solution to improve claims recovery (and management in general). Earlier this year, Fierce Healthcare pointed out, down to the dollar, how much it costs a payer to manage claim inquiries. “When a provider contacts a payer to check a claim status, it takes an average of 14 minutes and costs the provider $7.12… multiplied by millions of requests each year, the time and money add up. In 2018 alone, providers made 173 million claim status inquiries by phone, fax or email.” 

Investing in data analytics is a growing trend. In fact, 60% of surveyed health executives say they are investing more in predictive technologies in 2019. Claims recovery will continue to be an important facet of your health plan’s payment accuracy operations. With the right solution in place, the ability to shift to internal prepay concepts will be in your hands. 

 

The “Solution”: Pareo® is How

With a centralized solution like Pareo in place, everyone can get on the same page, including vendors and other departments responsible for payment accuracy. 

It may take time, it may necessitate a change in how you do things, but we believe all health plans have the opportunity to deploy a centralized solution for payment accuracy (and reap the benefits). Here’s an idea of how a PI solution like Pareo works from a holistic vantage point to quickly turn around recoveries at your health plan: 

Our team works with you to develop a specific implementation and use plan for Pareo that meets (and often exceeds) the goals you’ve outlined for your plan. If shifting to prepay cost avoidance is a goal of your health plan, Pareo is the comprehensive solution that will help you get there.

Talk to ClarisHealth about how Pareo®advanced payment integrity technology is helping health plans deliver on their most advanced digital strategies.

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.

Checking in: How to offer vendors a concierge experience

Checking in: How to offer vendors a concierge experience

When we created Pareo®, from its inception we knew vendors would be an important stakeholder in the payment integrity ecosystem. As our payment integrity solution has grown (in many ways, shaped by our incredible clients), it has cemented our belief that focusing on payment integrity suppliers is an important way we can better meet the needs of modern health plans. 

As you likely know, including more vendors in your payment integrity operations is likely to boost your recoveries. Yet, managing relationships with them can feel burdensome when we don’t have access to the right tools or information. That’s why we’ve set out to give those suppliers working with Pareo what I like to call the “Ritz Carlton experience.” 

That’s because — as with every relationship — you get from your vendors what you put in. We want to enable our clients to give their suppliers a five-star experience when working together. We developed Pareo Supplier Optimization to give your PI department all the tools they need to work effectively with vendors by boosting transparency, increasing engagement rates and contributing to improved recoveries. Perhaps you’ve discovered for yourself the value Pareo brings but you’re still looking for other ways to increase vendor experience. If so, read on.

Request a brochure and learn more about Pareo’s Supplier Optimization functionality.

7 Ways to Treat Your Vendors as Well as Customers

So much focus has been given to improving member satisfaction at health plans (with good reason — it’s important). But your vendors are such an important part of health plan operations, why not focus on their satisfaction as well? Are you giving them everything they need to help you maximize your return on investment? 

As you look to technology to improve supplier relationships, be sure to cover all your bases by striving for these 7 important functions that can lead to a better vendor relationship:

1. Share goals. The most successful vendor relationships function more like partnerships, rather than transactions. You both have the potential to provide greater value to the other.

 

“Vendor management is not negotiating the lowest price possible but constantly working with your vendors to come to agreements that will mutually benefit both companies.”

(source)

 

2. Communicate clearly and consistently. Transparency allows everyone to be on the same page. Both sides should be able to easily provide access to information on project progress — without asking for silo-ed status updates. “There may be issues between you and your vendor, but constant communication and a dedication to continuous improvement will make the difference,” writes Brian Fielkow.

 

3. Plan ahead. Set expectations on service level agreements, contract terms, etc. Surprises and emergencies are inevitable, but should be the exception with a well-thought out vendor plan. 

 

4. Pay on time. Their invoice should never be a surprise. Paying in a timely manner communicates to vendors that their work is valued.

 

5. Provide process training for your vendors. They have their area of expertise, which likely does not include “how you do things.” Set them up for success by bringing them to the table.

 

6. Be reasonable and accountable. Vendors are third-party stakeholders that rely on you in order to perform at their best. Likewise, you rely on them to meet their goals. Respect is a key part of the vendor-payer relationship and for health plans, that means being reasonable and accountable in vendor relations.

 

7. Make the most of meetings. The quarterly business updates that characterize most third-party payment integrity vendor relationships can be more valuable than out-of-date “status updates.” They can be meaningful strategy sessions, if the day-to-day communications are taken care of.

Talk to ClarisHealth about how Pareo®advanced payment integrity technology is helping health plans successfully implement their digital-first strategies.

Prepare to Meet the Future with Data

Prepare to Meet the Future with Data

We revisit ONC’s Information Blocking Rule, recap public comments, and look at how health plans can meet data sharing  requirements.

Earlier this year, we wrote about the ONC’s proposed information blocking rule and how it serves as an opportunity for health plans. The proposed rule faced a public comment period (which closed last month) during which major industry concerns were voiced. The consensus by many seems to be that ONC’s rule lacks clarification in key areas while inadvertently increasing complexity (and cost) in others.  

But as they say, “the writing’s on the wall” for health data interoperability and broader access to electronic health information. Where does this leave health plans? A recent study by Deloitte predicts that healthcare organizations are standing at the precipice of innovation. But first, let’s look at the feedback that the proposed information blocking rule received.

Industry Response to the Information Blocking Rule

One thing we can agree on at this point: interoperability is a major objective for our industry. But those who would be affected by the Information Blocking Rule have asked the ONC to revise or even revoke the current rule. This includes the Federal Trade Commission, who despite being consulted on the proposed rule, issued a letter asking the ONC to consider refinements. Notably, eHealth Initiative (eHI) offered the following comments and concerns

Scope of “Electronic Health Information” is too broad, should be defined

Conditions and Maintenance of Certification (APIs)

      • Too complex and costly as proposed
      • Too much risk to providers and patients, specifically the proposed “Click Yes to Continue” model does not adequately portray data security risk to patient

Information Blocking

      • Healthcare actors should be defined in the final rule
      • Complex and costly documentation requirements

Greater Data Sharing is the Goal

The ONC has stated that greater interoperability is the goal of the proposed Information Blocking Rule. Improved data sharing is a worthy objective for health plans because it’s an easy effort to prove value on. Health plans have a competitive edge over their counterparts when they are more integrated with providers and members. In addition to priming plans to be compliant with whatever final rule is based, improving access to data is also key to readying for other initiatives, such as alternative payment models

Of course, we know that total healthcare data interoperability sounds like the answer to all your challenges. But once the hard work begins of solving this problem, it can feel like data sharing at the level required is next to impossible. We’re here to tell you it’s not; interoperability is a realistic goal with the right technology

Let’s frame the objective of the ONC’s Information Blocking Rule in a more approachable way: Healthcare stakeholders need real-time, accurate and contextual data access. And the real challenges? Healthcare organizations still struggle with interoperability, largely due to issues like administrative complexity. Messy (as in, unstructured) or missing data is still a problem as well. 

We know that our industry is on the precipice of innovation. The recent study from Deloitte referenced above and in our prior article posits healthcare is on the precipice of a “20 to 30 year industry transformation. The industry forces and the disruption that’s upon us are true indicators that we’re going to be going through a cycle of innovation.” Innovation made possible by radical data interoperability. 

ONC’s Information Blocking Rule has 7 exceptions. Do you know what they are?

See the official list here.

The Promise of Big Data

Improved access to data is considered a consumer-driven shift, one often compared to the Amazon experience where a consumer can have on-demand access to personal information. But getting personalized, real-time electronic health data at the click of a button is a lot more complicated than it sounds. And it requires a special relationship that has historically been difficult: high-level collaboration between payers and providers. 

Yet this demand is exactly the kind of opportunity health plans can seize upon as they search out competitive ways to utilize big data. Examples can be seen in the use of predictive analytics to mitigate risk, noted in this article as a “massive moneysaver” by one health plan who made a big IT investment. Reams of data are available to health plans — all that’s lacking is the right way to connect and analyze it. 

“Improving relationships with members and providers is already a focus for health plans, and data sharing is another way to accomplish that goal.”

Health plan of the future? It starts with data sharing.

One way of looking at the Information Blocking Rule is that it’s a proposed answer to a problem that health plans can take control of now. Improving data sharing isn’t just a proactive approach to anticipated regulation — it’s becoming an essential business function for health plans. To get started, health plans can focus on these three areas: 

Develop data analytics and predictive modeling know-how

Take advantage of opportunities to break down data silos by fostering relationships with providers, members and vendors

Look for existing technology that can support these goals: bring disparate data together, simplify data modeling, and provide a transparent communications platform

The future of data sharing is now. Pareo® is how.

Talk to ClarisHealth about how Pareo advanced payment integrity technology is helping health plans successfully implement their digital-first strategies. 

What makes value-based care programs work? 3 keys to success

What makes value-based care programs work? 3 keys to success


Following up on our previous article, we look more closely at what successful value-based care initiatives have in common.

It’s not all that surprising that one of our recent blog posts, Medicare for All: Should it be feared by health plans? has quickly become one of our most popular. Value-based care programs, like what the federal government has switched to, are at the forefront of discussions regarding the future of healthcare. And a recent survey indicates that providers are actually willing to take on more risk under alternative payment models, which signals well for value-based care adoption. 

But it takes awhile to implement value-based care programs and that may leave many health plans wondering what they can do to be proactive. Here are 3 strategic initiatives your health plan can pursue today to ensure value-based care programs will be successful on down the road. 

1. Communication

We’ve talked a lot lately on the blog about communication and collaboration and with good reason: the future of healthcare demands it. As care models shift, the need to work effectively with other vested parties is paramount. 

Take for example a recent panel in which industry experts (18 in all) were asked to define the term “value-based care.” While the term “value-based payment” was broadly agreed on, experts could not come to a consensus on the meaning of value-based care reports FierceHealthcare. “In addition to these specific gaps in communication, the study highlighted just how valuable it can be for industry leaders to convene with others who may not share the same perspective,” says Meredith Williams, M.D.

Health plans can prepare for  value-based care by fostering better communication with internal and external stakeholders. As Williams points out above, sitting down with other experts in the industry to get on the same page is a powerful — and unprecedented — move. 

2. Transparency

Alongside value-based care runs another initiative: transparency. Real-time access to crucial medical details, patient access to data, and upfront pricing are goals associated with successful value-based care programs. 

True transparency is only possible when health organizations have a firm grasp on data. Yet interoperability remains a struggle: 74% of respondents in this survey list the “ability to aggregate and share information as an extremely important need over the next three years.” By 2020, 59% of healthcare payments will be from value-based care models, and that means health plans need to work now on integrative data strategies. 

A shift towards transparent practices can directly affect your health plan’s relationship with providers. The ability to collaborate with elements of the healthcare trifecta (patient, provider and payer) will grow increasingly important for health plans seeking to thrive in a value-based care environment. “If value-based care is about aligning what works best for the patient to a hospital’s financial incentives, then insurers and providers must work together to create the best outcomes,” writes Healthcare Finance

3. Technology

With communication and transparency as actionable goals for health plans seeking to prepare for value-based care, technology is a third and crucial piece of the puzzle. With the right technology solution, health plans can improve communication and engagement with key stakeholders while promoting more transparent data practices. “Data is much easier to connect with when you are able to see it in real-time,” notes Jason Medlin, ClarisHealth VP of Marketing & Business Development. 

Investing in IT and technology to foster innovation was a featured conclusion of the Deloitte report “The Health Plan of Tomorrow.” Switching from volume to value in healthcare models will require a sophisticated technology strategy. The goals of value-based care programs — largely focused on access to patient care data — are not currently achievable at many health plans. 

The fastest way to transform? Technology, says Healthcare Finance. A comprehensive payment integrity solution should also provide a way of interpreting big data to transfer into actionable insights. “Once an organization has its data and is able to analyze it, it can then pinpoint opportunities for changing the practice to improve efficiencies without compromising quality outcomes — and for improving patient care overall.”

The Healthcare Trifecta Matters More Than Ever

Payers, providers and patients make up what we refer to as the “healthcare trifecta,” and the effectiveness of this relationship directly correlates with the success of value-based care models. Even as payers and providers work towards improved collaboration and communication, health plan members also  seek more ready access to information. Health plans who focus on supporting and improving their relationships with providers and patients are poised to adopt value-based care more successfully.

Talk to ClarisHealth about how Pareo®advanced payment integrity technology is helping health plans successfully implement their digital-first strategies. 

Should You Build Your Own Supplier Management Solution?

Should You Build Your Own Supplier Management Solution?

Take our quiz to help you decide if build or buy is right for your health plan. 

By now, you likely realize that your health plan needs a way to manage the many third-party vendors that allow you to maximize recoveries and optimize costs. The question is, should you build a solution internally or buy one?

We routinely run across health plan stakeholders in the midst of customizing their claims editor and other resource-intensive but relatively manageable IT projects. Most recently, we encountered a health plan considering building their own vendor management solution. That they need a solution is understandable. That they plan to build it themselves begs the question, “Are you a health insurance provider or a technology company?”

You know building your own software is going to cost more than you budgeted for, your IT resources are already constrained, and your expertise may be limited. But if your needs are truly unique, why look for a flexible, robust technology solution created with the support of industry-wide insight when you could devote millions of dollars to a solution of your very own?

In all seriousness, building a software solution with the ability to plug into dozens of independently-operated platforms (as in the case of third-party vendors) requires some heavy lifting. Are you ready? Let’s find out!

Should You Build or Buy a Vendor Management Solution? The Quiz

To take this quiz, view the following slideshow and record your answers. 

 

Results

 

Perhaps you’ve already tried to build your own IT solution, and it didn’t go anywhere. Or maybe you’re on the fence about building something that’s already on the market. However, you aren’t sure if what’s out there is really what you need. Not all vendor management solutions are the same, and we’ve learned that our clients appreciate the customization opportunities that Pareo® offers. In fact, we offer the ability for health insurance providers to completely outsource vendor management to us.

Because you’ve likely tried to build a software solution before, you may face internal pressure to just “make it work.” Here’s a helpful guide that discusses what it takes to successfully develop software (hint: It’s not simple). Borrow a page from tech company playbooks and take a realistic approach to any internal software development efforts.

You may – or may not – be able to successfully build your own vendor management solution. But it’s important to ask if IT development is really your true calling. Most health insurance providers we speak with develop internal software solutions as a means to an end. They quickly realize that the upkeep and maintenance associated with these insular solutions is not manageable. That’s because building an internal IT solution isn’t the same as buying one from a company whose sole focus is solving the types of challenges your health insurance company faces.

“Technology alone delivers no value. It’s the combination of a clear strategy, the right technology, high-quality data, appropriate skills, and lean processes that adds up to create value. Any weak link in this chain will lead to poor value delivery from IT,” writes McKinsey. As you evaluate whether or not to build or buy your own vendor management solution, consider all the elements at play. Technology alone isn’t enough; to be successful, you’ll need a force behind your internal IT development.

You are the healthcare insurance unicorn – an IT-heavy, resource-laden organization that really can build your own internal software. We would ask you though, why reinvent the wheel? If a great vendor management solution does exist, and can be customized, why not tackle a software development project for which there isn’t already an answer?

“Building custom software can unlock a host of benefits, but companies should only pursue that strategy if a) better software can provide a competitive advantage relative to your competitors, and b) you are building a large business that can spread the cost of a proprietary system over a large number of clients,” writes one Forbes contributor with experience on the matter.

Taking on a software development project like this may derail your small IT resources, who would be better focused on their core competencies. We suggest exploring solutions that are already built and extremely customizable, like Pareo®. Not only do we offer the technology you need to manage multiple third-party vendors, but we also walk small health insurance plans through the steps of payment integrity program creation. Still sound like a little more than you’re ready for? Consider completely outsourcing vendor management.

By outsourcing vendor management, you can quickly implement a successful payment integrity program that your IT department can plug into. Consider what qualifies as “good” when it comes to vendor management: “Good vendor management allows your organization to build a successful and stronger relationship with your suppliers or service providers.” Can you really do that if your time, attention and money are caught up in developing software to manage vendors?

Final Thoughts

In an age where customer-centric technology projects are increasingly consuming the insurance industry, building a supplier management solution yourself may just be a waste of time. We developed Pareo® to specifically address the concerns of this industry: Function, Flexibility, ROI.

In fact, it’s not uncommon for Pareo® clients to see a 10x return on their investment. Read our latest case study to learn more.

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