What is payment integrity?
Payment integrity is the process by which health plans and payers ensure healthcare claims are paid accurately, both in a pre-pay and post-pay context. It encompasses determining the correct party, membership eligibility, contractual adherence, and fraud, waste and abuse detection and prevention.
Why is payment integrity important for health plans?
Payment integrity is a major component of a health plan’s overall cost containment strategy. In fact, many health plans are reorganizing their disparate functional areas and systems under a centralized payment integrity function. This function can contain many elements, including Coordination of Benefits; Fraud, Waste and Abuse; Appeals Management; Subrogation; Provider Communications; Special Project Referrals; and Vendor Management.
This growth in significance can rapidly expose weaknesses and gaps in a plan’s payment integrity operations and create questions around how to optimize investments, increase pre-payment cost avoidance, and maximize business value. Answering these questions can seem nearly impossible without an enterprise payment integrity technology platform to more effectively manage the many functions, processes, and systems that now comprise payment integrity.
What payment integrity gaps exist at health plans?
In our consultations with health plans, we find a number of gaps in current processes that are more effectively resolved with enterprise technology. Examples include the lack of coordination between internal and third-party claims identified for audit, limited IT resources to address the need to grow internal analytic capabilities, and the difficulty in establishing third-party vendor goals and holding each accountable to those goals.
In addition, process improvements are slow to develop at many health plans and internal silos create unnecessary inefficiencies. Legacy, vendor-led payment integrity solutions tend to focus narrowly in one area without addressing the bigger picture. At the same time, the lack of integration between internally developed tools and other systems and programs results in duplicate work.
What kind of solution best addresses payment integrity?
Comprehensive, enterprise-wide software that covers all payment integrity components is best. Specifically, health plans should look for technology that includes vendor overlap management, predictive modeling, advanced analytics, efficient workflows, provider engagement tools, medical records storage, and financial recovery management. This Total Payment Integrity approach enables end-to-end oversight on claims payment accuracy programs and renewed focus on advanced data management capabilities that improve health plan financial performance.
What makes ClarisHealth a good partner?
There are 4 distinguishing characteristics.
- Our innovative payment integrity technology platform Pareo® is the most comprehensive solution in the industry and is transforming the ways in which health plans organize and execute on their program initiatives.
- Many of our team members have been in the payment integrity space for 20+ years, and we use this expertise to bring a more consultative approach to our health plan partners.
- By virtue of Pareo®, we bring complete transparency and accountability to the entire payment integrity process with results squarely focused on root cause resolution instead of an endless cycle of pay-and-chase.
- We provide a full suite of technology-enabled payment integrity solutions that are specific to a health plan’s needs.
What kind of ROI can health plans expect on payment integrity technology?
We are seeing health plans realize an 8x-10x minimum return on investment through a move to more internal payment integrity initiatives, increased vendor efficiencies, growth in internal pre-payment recoveries, and lower administrative costs. Payers that adopt scalable enterprise payment integrity technology platforms like Pareo®, or bundle Pareo with a customized services offering, commonly triple their medical savings.
What is Pareo®?
Pareo® is an enterprise payment integrity technology platform that is transforming health plan cost containment operations. Pareo means “to reveal” and this solution provides the total visibility across systems and stakeholders that health plans and payers need to maximize recoveries.
With its ability to integrate all claims overpayment inventory end-to-end — whether prepay or post-pay, outsourced or insourced — clients have likened Pareo to a payment integrity operating system.
What results can payment integrity realize from enterprise technology?
Health plan payment integrity organizations can achieve more recoveries faster, improved productivity, and cost savings from automation from integrated technology platforms. Altogether, according to our research, these improvements can result in 3x the medical savings over health plans that don’t use enterprise technology.
Pareo clients, specifically, recover overpayments 50% faster, increase recoveries 31%, and increase identifications 21% after the first year of platform adoption. These improvements are connected to Pareo’s unique ability to integrate data, digitize processes, scale content management, and automate recovery processes.
How can payment integrity operate more strategically?
Payment integrity organizations have shifted away from the “nice to have” role they used to play in health plan operations. Today, this function’s contribution goes beyond recovering found revenue. Payment integrity contributes to medical savings as well as relationships with group clients, provider network participants and members — all areas of strategic import to payers. By offering relevant operational insights that connect these dots, payment integrity can demonstrate enterprise impact and operate more strategically.