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 Third-Party Services.
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 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 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, internal silos create unnecessary inefficiencies, current payment integrity technology solutions tend to focus narrowly in one area without addressing the bigger picture, and the lack of integration between internally developed software and other systems 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 will enable process continuity and a new 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 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.
- We provide a full suite of payment integrity services that are customized 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. It is common to see a 4% decrease in medical expenditures as a result of adopting Pareo® as a standalone solution or bundling Pareo® with a customized services offering.
What is Pareo®?
Pareo®is a comprehensive 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.