Payers need a proven framework for payment integrity to create financial value, handle change, and engage at the highest levels of organizational strategy. This 5-step methodology works whether the directive is accelerating growth, building from scratch, or somewhere in between.
Healthcare costs are increasing, and health insurers can expect — by some estimates — to spend 7 percent more in 2024. In this environment, payment integrity teams have a strategic imperative to optimize.
But that same economic dynamic demands smart investments. To get buy-in on progressive strategies, payment integrity leaders must determine the right time to invest in programs with a keen eye to value.
Tareyn Gillilan, currently VP of Business Operations with WellSense Health Plan, has developed a scalable and understandable framework for investing in payment integrity. Over her last ten years leading payment integrity strategy at different health plans, this methodology has proven successful in creating value for programs at various stages of maturity.
“To engage at the highest levels of organizational strategy, payment integrity organizations need to be able to handle change and create financial value,” says Gillilan. “That’s true whether the directive is accelerating growth, building from scratch, or somewhere in between.”
5-Step Building Blocks Framework
The framework Gillilan has found success working from can elevate a payment integrity program or team working from any level of maturity.
“I rate payment integrity program maturity across five basic dimensions: emerging, limited, developing, centralized, and optimized,” Gillilan maintains. “In just the past five years, I’ve seen payment integrity organizations mature to where a much greater percentage see their programs on the developing or centralized side of the continuum.”
With that rate of progress in the industry, a predictable, logical approach to taking the program to the next level can prove invaluable. The five steps in this building blocks framework are simple and repeatable, so it can grow with an organization as it further matures.
1. Assess the program’s people, process and technology
The first step of the methodology is getting a full accounting of the current state. That can begin with a straightforward listing of the programs, teams, and/or support operations involved in the strategy, ordered by their relative financial impact. This list can include payment integrity verticals as well as supplier management, data and analytics, group management, provider scorecarding, and more.
Then, each can be evaluated on its three primary building blocks: people, process, and technology.
“I like to use a red-yellow-green color code because it’s intuitive and easy to assess at a glance,” notes Gillilan. “Broadly speaking, those indicators tell me if my people, process, and technology blocks are not available, need work, or are fully operational.”
Gillilan often completes this assessment in a group whiteboard session. What emerges is a fuller picture of where the program stands — as well as where it can go. As she explains:
“When you push yourself to assess where you stand, you also start figuring out that vision of the future, which gives you a great platform to get needed buy-in. Executive leaders will be very interested in what potential results you foresee.”