In the face of economic and hiring constraints, payment integrity leaders are prioritizing these 4 best practices to shift to an enterprise strategy that offers proven value.
How can a strong payment integrity foundation reduce administrative spend?
Health plan leaders acknowledge that challenges abound in meeting payment accuracy goals. Communication with providers, aging technology solutions, industry mandates, siloed data, hiring challenges, and budget constraints all present hurdles. At the same time, payment integrity is still rising in organizational strategies.
In this environment, payers are prioritizing best practices on proven standards that guarantee a return on investment. They’re going back to basics — and finding real value in the process.
Here are the top four best practices payment integrity leaders are focusing on to strengthen their programs and strategies.
1. Quantify the value of outsourcing to support strategic goals
Outsourcing claims overpayment reviews and audits to third-party vendors is a common approach payers take to manage payment integrity. On average, payers use two to seven vendors to help cover their programs. But, at an average IT cost of $250k per vendor, this strategy may prove inflexible in the face of concerns around administrative costs. On top of this, running an array of vendors creates too much manual work to chase valuable insights.
Many payers are finding that using technology to right-size these vendor relationships offers more value for both sides:
- Standardized data integration can lower the cost of vendor implementation and onboarding.
- Integrating these vendors with the help of a payer-controlled technology platform offers a near real-time and longitudinal view into performance metrics representing true efficacy.
From there, payment integrity leaders can use the information generated by more traditional recovery efforts to surface trends and overpayment traits that are prime to shift to prepay and/or insource. Instead of finding the same recoveries over and over again, they position vendors more strategically as outsourced R&D and specialized experts.
2. Maximize recoveries to support a shift to prepay
Most payers continue to goal toward a model of primarily prospective cost avoidance. And with good reason. According to a recent industry report:
“Prospective payment integrity decreases administrative burden for both payers and providers by significantly improving the accuracy of the initial claims determination and payment.”
But there are two things to keep in mind with this goal. The first is, due to timing and complexity, a certain percentage of overpayments always will be recovered retrospectively. The second is, comprehensive post-pay recovery forms the foundation of accurate prepay programs.
Consider the use of predictive analytics to generate prepay concepts. This technology relies on compiling historical results to improve precision. By ensuring all areas of payment integrity are covered — coordination of benefits, data mining, medical record review, contract compliance, and fraud and abuse detection — a more complete picture of post-pay activity emerges. And a thorough post-pay strategy that produces aggregated insights also helps leaders further evaluate provider claim submissions for education opportunities.
This coordinated root cause resolution effort not only leads to prepay savings, it gives payers an opportunity to optimize costs by revealing areas of their post-pay program that could be shifted internal.