Maximize Value & Partnership with Your Third-Party Payment Integrity Vendors

Feb 27, 2018

Ask yourself these 6 questions to get the most from your payment integrity vendors.

Looking to get the most out of your third-party payment integrity solution vendors? Consider asking yourself the following questions to determine if your vendors are providing you with all that can be offered in a payment integrity solution.

Do you have all areas of the health plan covered?

Astute health plans and payers will determine if their payment integrity solution offers medical savings across all lines of business including commercial or fully insured, government, or self-insured/ASO as well as one level deeper into the complex medical and behavioral specialties where reimbursement issues and waste and abuse can arise.

If you want to get the most from your vendor, it’s best practice to identify any gaps in your payment integrity coverage so that returns can be maximized. This process can be made much more efficient through the use of technology. Solution-oriented software like Pareo™ aims to resolve inefficiencies and maximize returns for clients.

Do you have multiple vendors stacked across all of your services?

The use of multiple vendors – the right vendors, strategically arranged – is essential to maximizing savings. While some vendors can offer multiple solutions very competently, there is significant value to identifying vendors for individualized niche services, especially after identifying your gaps. For instance, multiple vendors mean that you have several sets of eyes on data and, through the use of an integrated system, this data isn’t siloed.

Historically, finding and managing multiple vendors, each with their own niche of expertise, quickly adds up administrative costs for health plans. But, with technology to manage vendor overlap, claim file distribution, and efficient workflows, plans can expand their vendor profile without a corresponding increase to administrative costs.

In addition, focus on the quality of your vendors. Some payment integrity solution vendors offer more value than others, so hone in on a solution that can demonstrate a proven ROI. Recently, at sixth-pass, ClarisHealth uncovered $5M on a large Medicare Advantage plan for a client. Total payment integrity is a solution that focuses on the big picture, saving a health payer administrative time and costs.

Are you optimizing your recovery costs while maximizing vendor savings?

When it comes to payment integrity, the savings can be big – but the solutions can be expensive. Health payers should consider what their vendor solution offers to enhance pre-payment cost avoidance, a trend gaining considerable popularity. Additionally, a health plan cannot afford to overlook post-payment recovery solutions.

Health plans should leverage technology to identify leakage to their vendors and identify areas to internalize at lower costs:

  • Can leakage be identified through lower cost first-pass vendors, and then can those savings be applied to second- and third-pass vendors? If so, the outcome yields greater returns.
  • Can overpayment identification be internalized at a third of the expense of outside vendor fees?

When an advanced payment integrity technology solution is deployed in this manner, plans can maximize their value for 4-6% of recovery versus 15-20%.

Do you classify your vendors as an extension of your R&D function?

A way that health plans can maximize the value of third-party payment integrity vendors is to factor in their ability to facilitate research and development operations. Specifically, a payment integrity solution vendor should provide overpayment concepts to their clients on a regular basis. If a third-party vendor cannot show that they update this R&D function regularly, a health plan should look for a solution, like Pareo, that does.

To offer maximum value, a payment integrity solution must accommodate vendors regularly submitting new concepts to clients so that, over time, these concepts can be internalized. This utility for open communication and feedback improves internal health plan operations and is the hallmark of holistically-minded, technology-driven payment integrity solutions.

Now’s the time for total payment integrity

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

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