May 16 2018 | 0 Comments | 191 reads Average Rating: 3

Looking to Advance Your Payment Integrity Journey? Time to Embrace Innovation

by EXL Healthcare and Monique Pierce in Payment Integrity

With healthcare costs, aging populations, patients with chronic conditions and overbilling schemes all on the rise, payment integrity is more important than ever. As such, payers need to make sure that they have payment integrity basics down – while also striving to implement audit innovations that deliver benefits more expediently with reduced administrative burden and greater success.

As such, your health plan needs to make sure it is optimally leveraging tried-and-true payment integrity tools such as high dollar claims review; fraud, waste and abuse detection; coordination of benefits; and subrogation. While these programs form the foundation of payment integrity programs, you also need to innovate to meet ever-expanding challenges.

Prepayment audits deliver the trifecta of benefits by producing improvements to payment speed, quality and costs.

Prepayment auditing, which makes it possible to identify improper payments before they are paid and reduce waste in the payment process, is one such innovation. Fortunately, with technology, data analytics and system interface advancements, it’s now possible to complete complex audit reviews leveraging a member’s medical records within the initial prompt-to-pay timeline and, therefore, avoid overpayments. As such, prepayment audits deliver the trifecta of benefits by producing improvements to payment speed, quality and costs.

Behavior modification is another cutting-edge innovation that your health plan should consider. Such initiatives can better control medical costs for claims that typically fall outside the purview of traditional audits such as non-par providers and higher volume, low-dollar claims. Indeed, by using advanced analytics and workflow management systems, you can identify and manage provider outliers based on cost and utilization. More importantly, perhaps, you can change billing behaviors by engaging these providers with education and support.

Such behavior modification programs typically involve the following six steps:

1. Create suspect list based on peer-to-peer analysis

2. Validate suspects based on stratified audits

3. Identify outliers based on cost and utilization

4. Measure and rank providers

5. Engage providers to promote desired behaviors

6. Monitor and measure results and outcomes

By implementing the following steps, your health plan will be able to expand your payment integrity efforts, making it possible to:

  • Capture errors that are currently “under the radar” of existing payment integrity solutions
  • Address the root causes of billing errors, enabling your organization to zero in on lower dollar, higher volume claims
  • Cement positive lasting changes to provider billing practices
  • Reduce overall provider abrasion
  • Address issues with non-par providers

Here, we’ve discussed a couple of innovative ways that you can advance your payment integrity journey. Can you think of other potential innovations? For a more comprehensive discussion of payment integrity, check our webinar entitled Expanding Frontiers: The State of Payment Integrity in 2018.

Watch on-demand webinar | View webinar slideshare

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EXL Healthcare

Monique Pierce
Vice President, Business Optimization

Monique Pierce is Vice President of Business Optimization at SCIO and an experienced leader with operational, product and program management accountability and expertise.

Read full profile and other posts |

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