Don’t Settle for “Just” A Claims Editing Solution

May 9, 2018

Look beyond claims editing solutions and find a comprehensive solution to payment integrity.

If your payment integrity strategy is limited to just a claims editing solution, your health plan is falling short on the payment integrity continuum. Health plans that think beyond claims editing see bigger returns and make strides toward the holy grail of a payment integrity program: cost avoidance.

Let’s start by taking a look at what your health plan could be missing out on if a claims editor is the sum total of your payment integrity efforts.

Mind the gaps

Claims editing, built into an adjudication system, will provide a health plan with some benefit but it also leaves many gaps. For instance, choosing only a claims editing solution:

  1. Limits a health plan’s post-pay identification efforts.
  2. Makes proving the ROI on claims editing efforts much more difficult. There are no internal analytic capabilities, and even if there were, they’d only be showing one part of the payment integrity process.
  3. Overlooks goal setting and accountability capabilities needed to better manage third-party services vendors.
  4. Inadvertently contributes to data silos (a problem that CMS is actively taking on) by addressing only one piece of payment integrity.

These gaps all have one thing in common: they all lead to greater inefficiency and limit productivity. Progress along the payment integrity continuum can be measured by a reduction in the number of manual interventions required to keep things running smoothly for a health plan. No matter how automated your claims editing solution, the data silos alone created by this short-sighted approach can negate any gains.

Expand your opportunities

In contrast, total payment integrity consists of a more comprehensive solution to many moving parts, addressing the gaps of claims editing software by offering data mining, coordination of benefits (COB), and third-party vendor coordination.

Rather than addressing one singular aspect (claims), a health plan can extend their efforts and better manage their revenue operations by utilizing a more comprehensive platform that views payment integrity as a holistic program. In addition to claims editing, a total payment integrity solution opens up a whole world of opportunities for health plans:

  • Improved post-pay activity with first-pass, third-party vendors for major services (such as data mining, clinical audit, and COB) which complements internal post-pay efforts.
  • Comprehensive post-pay activity with additional vendors and introduction of FWA technology. With a total payment integrity platform, a health plan can leverage vendors as R&D to expand internal post-pay efforts in order to optimize spend. This reduces the amount of manual intervention required to effectively manage third-party vendors.
  • A third-party, post-adjudication pre-pay vendor to complement post-pay and FWA efforts.
  • Adding post-adjudication pre-pay with internal pre-pay operations in advance of third-party solutions. This ensures a health plan is continuing to round out post-pay activity.
  • With total payment integrity, all lines of business are addressed pre- and post-pay. Plans realize cost avoidance in excess of 50% of overall plan savings. Dynamic solutions are put in place to continuously evaluate and move post-pay identifications internally, ultimately leading to avoidance.

Where is your health plan on the payment integrity continuum?

Total payment integrity offers health plans a comprehensive platform with integrations and tools that require fewer manual interventions. As you take stock of where your organization falls on the payment integrity continuum, keep in mind that the current healthcare climate seeks transparency and access to quick information.

A claims editing solution falls at one extreme of the continuum, as it silos information and limits (or fails to supplement) post-pay identification efforts. Such an approach may be a temporary band-aid for health plans seeking to stop payment leakage, but it won’t hold for the long term.

What is required in order to stay on the progressive end of the continuum is addressing claims on a pre- and post-pay basis, while cost avoiding more than 50% of overall plan savings. Total payment integrity is a possibility that is achievable for health plans, especially those who are committed to seeing the bigger picture.

Learn more about the ClarisHealth 360-degree solution for total payment integrity, Pareo.

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