Payment Integrity: Can We Get It Right?

Payers are capitalizing on payment integrity trends more than ever before, but inaccuracies continue to plague the healthcare system—contributing to the estimated $760-$935 billion dollars in annual health system waste. Administrative complexities and pricing failures are expensive for payers and increase provider abrasion and healthcare costs for members.

The problem is multi-faceted, which is why most payers take a disjointed approach to solving the 5-8% of claim dollars paid inaccurately. Multiple departments within a payer organization may use various methods, investing in duplicative solutions with separate incentives. While this may address individual problems within a department, the larger issues of transparency for providers and solving for the source of inaccuracies remain elusive.

With reliance on multiple vendors (and instances) throughout the organization, several main issues contribute to miscommunications, lack of transparency, and improper payments:

Out-of-sync update cycles: Vendors often deploy update cycles at different times, resulting in policy and fee schedules that conflict. While sometimes entire teams at payer organizations are employed to manage and coordinate the multitude of updates, they remain daunting and disruptive.

Lagging updates: Payers routinely receive or make updates to policy and fee schedules after the regulatory deadlines with further delays due to IT implementation and testing of updates. This, of course, leads to claims being improperly paid and contributes to downstream payment integrity activities that could have been prevented with up-to-date data.

A complex, siloed stack of solutions: Many payers have spent 30+ years adding technologies and processes that lead to a tangled web of data compounded by vendor management challenges, conflicting results, and costly upkeep.

“The goal is to tie together disjointed components of the payment process so that complex communications can be translated into a common language.”  – Jared Lorinsky, Chief Strategy Officer, Burgess

Recognizing these issues, some payers with enough internal expertise, IT maturity, and certain provider characteristics, opt to insource payment integrity capabilities. While this approach removes the problems associated with reliance on multiple vendor solutions, it also eliminates the possibility for vendor insights and collaboration while taxing internal resources.

Alternatively, too much reliance on vendors often keeps payers focused on incremental savings and relinquishes control (and insight) of payment integrity functionality. This model continuously patches a broken system and hinders long-term business goals and opportunities for transformation.

As we move beyond interoperable systems toward the opportunity for complete digital transformation, the question remains: how can we walk a fine line that involves the right vendors for their expertise and insight without overcomplicating an already complex system?

Improve Transactions, Enhance Member and Provider Relationships

Every day, the limitations of legacy systems cause health plans to waste money and time fixing improper payments, leading to strained budgets and relationships with providers and members.

According to a recent survey of more than 220 health plan executives, when asked what has the greatest negative impact on satisfaction, it comes down to underpayment/overpayment/delays in payment and need for access to real-time data for providers and surprise billing/difficult transactions for customers.

It’s clear that health plans want to create better experiences for their core constituents. The survey also revealed that increasing member satisfaction and improving provider relationships are the top two organizational goals for payers.

In fact, increasing member satisfaction has remained the top organizational goal since 2018. While executives remain focused on finding ways to gain approval from their members, we’ve seen more emphasis over the past year on improving engagement strategies as part of this focus.

However, for members, the transactions with health insurers do not feel natural—it’s completely different than any other transaction consumers engage with every day.

As HealthEdge CEO Steve Krupa said on the #HCBiz Show! Podcast:

The analogy that I often go to is Amazon. When we think about Amazon and its capabilities today, we see an awesome consumer front-end experience and a great supplier backend experience where suppliers can adopt the Amazon platform and use it as a place where they can do business. Those experiences are fundamentally enabled by an autonomous transaction engine. Amazon invested in [developing] the capability to manage transactions as close to real-time as possible … and the transaction engine produces data, information, and insights that have led to a very intuitive and efficient marketplace for customers and suppliers. 

More streamlined transactions are happening across every single industry. Consumers expect their interaction with the health system to resemble the customer service they’re used to, if not better.

If health plans want to create a similar experience for their members and providers, they need a next-generation core administrative platform with data-sharing capabilities that enables them to innovate their business models and push toward a better transaction process.

To improve provider and member satisfaction, health plans must invest in forward-thinking, next-generation technology solutions that offer a better experience with efficient and accurate payments – the first time.

Regulation: Innovation Springboard Rather Than Compliance Checkbox

The industry traditionally has addressed compliance requirements by solving for the Rule and waiting for specifics to come out of CMS, or other agencies, before taking any action. We need to stop solving compliance requirements for the moment and take a more holistic approach.

My personal mission is to change the mindset of health plans to use regulation as a springboard for innovation rather than a checkbox for compliance.

With any compliance mandate, there is a good intention behind it. Health plans should figure out the intent of the Rule, why are we doing it, and what is the best way to accomplish this that will benefit the entire healthcare ecosystem?

For example, take the CMS Interoperability Payer-to-Payer Exchange of Historical Data Rule, coming up in January 2022. The Rule allows for a member enrolling in a new plan to request that the plan from which they are disenrolling extract and send up to 5 years of historical data to the new plan; And the receiving plan must be able to accept that information. As a result, data will move with a member rather than being left behind.

The Rule just says what payers must do: send and receive the information, but the intent of the law is to use the data to improve care. The exchange of data is the “easy” part; the use of the data by the core administration systems to improve members’ overall health is the desired outcome of this and other compliance requirements.

At HealthEdge, we do not look at compliance simply as a check box. We are looking not only at how we support our customers’ ability to comply with the rules but also the why behind the Rule; Aligning the solution with the impacted business process in the best way to achieve the results we need in a highly regulated environment.

I want to help health plans go beyond achieving compliance.   I encourage you to look at compliance from the perspective of process re-engineering, considering the intent of the rulemaking, identifying the value it brings, and what benefits can be created as a by-product of the Rule.

In our digital world, this is where plans will distinguish themselves and create a reputation for partnering with members and providers to enable quality and affordable care that is member-centric.

Business Process as a Service, Redefining the Future Health Plan Operations Model

An uptick in the market trending over the past three years is the Business Process as a Service (BPaaS) model, where health plans outsource their platform and some to all of the operations tasks based on strategic needs. Though not new, this is becoming a mainstream shift and will likely continue to grow and evolve moving forward.

With this model, health plans looking to gain competitive edges will find an entity that partners with a software vendor and create its own platform using a core technology solution. That BPaaS partner will already have built enough of the ecosystem to host a client and provide key business processes as a service.

These BPaaS providers offer streamlined implementations and a low-cost approach to the solution, including creating different instances and environments for their clients as they onboard them and cater to their specific needs.

This model gives health plans an advantage by enabling them to drastically reduce the need for in-house operations and IT staff while maintaining strategic control of the plan and membership. The BPaaS model is also valuable for smaller plans looking to achieve higher auto adjudication rates or solve specific business problems to improve their business (for example, system consolidations or legacy sunsets).

They can partner with organizations that can help them achieve those goals faster than they could in-house based on the collective experience and best practices brought to the forefront.

A few years ago, it was in one out of every five or so RFPs, would be looking for a full ecosystem and operations support.  Now BPaaS has gained popularity and is either somewhat in scope or completely in scope for every RFP it seems that comes in the door.

Currently, the list of established BPaaS partners in the field is limited. Yet every month that passes, the market continues to see all kinds of new players pop up with the mindset of disruption leveraging this model.

I foresee an increasing number of software vendors and other technology-driven entities either providing the core solution or creating their own BPaaS offerings.

As technology moves forward and digital transformation becomes prevalent in these solutions, it makes it very exciting to see what is next in this evolution of the market supporting health plan operations.

Voice of the Customer Drives Innovation

I’ve worked in the healthcare industry for over 30 years and with Burgess for a little over ten years. At Burgess, we strive to anticipate the clients’ needs before they are even aware they have the need. We’re always looking for the next problem to solve to make the clients’ experience better and ultimately shift the overall healthcare system forward into the future.

We value our customers’ input. Getting client feedback is important and allows us to build a better product. When we introduce a new feature, we love to get positive reinforcement from our clients because it confirms that we’re hearing them, understanding them, and building and delivering the right solutions.

On the other hand, if we receive not-so-positive feedback, we always turn that into an opportunity to improve the product and make the customer’s experience better.

While there are certain problems that all of our clients share, each company experiences unique challenges; this requires us to detect those nuances and dive deeper to understand the client’s specific needs, what they want to achieve, and how we can find a solution.

Several capabilities we’ve built into the product over the years have started with one client’s particular need. For example, one of my customers recently had a special need for pricing a provider contract provision. Coincidentally, one of my colleagues on the service delivery team was working with a different client that raised the same issue three days earlier. This immediately signaled to us that this function was not just a “nice to have,” but could offer value to a range of clients. Through ongoing collaboration by listening to and sharing our clients’ feedback internally, gave this enhancement―and other features in the past― the traction and attention it needed to move forward.

The best part of my job is working with our clients. I enjoy helping our customers improve their workflows and processes, do things more efficiently and cost-effectively, and achieve their goals.

Doing Well by Doing Good

HealthEdge CEO Steve Krupa and I both graduated from The Wharton School at the University of Pennsylvania. Benjamin Franklin, who founded the institution that became the University of Pennsylvania, advised Americans to “do well by doing good,” an early and broad expression of stakeholders. He founded the Colonies’ first subscription library, a volunteer fire department, and a property and casualty insurance company to spread catastrophic risk along with founding his adopted colony’s leading educational institution. It was a mix of profit and non-profits exhibiting an advanced view of how individual success and the success of your community are inextricably tied together.

Historically, there has been a view that in order to do good for society, one must work for a non-profit, work in government, take a vow of poverty, or work in some bureaucracy. However, business is also part of the answer to creating social change.

Through Wharton and its other schools, UPenn has begun to offer programs to build the skills for social entrepreneurship, where students can learn how to develop business plans for both non-profit and for-profit ventures that contribute to social change.

Dr. Ariel Schwartz, Post-Doctor Fellow at UPenn’s Center for Social Impact Strategy, said, “the activity of any sustained venture—a business, a non-profit, a government, a university—has an effect on the world. And the effect of any organized action that systematically engages with the market or a group of people in society can be positive or negative…With careful planning, any venture in any sector can use its financial, social, technological, and knowledge resources to leave a lasting systematic positive mark on the world.”

HealthEdge values social entrepreneurship and aligns our company’s goals with what is good for society to contribute to positive social change through our business. We recognize that capitalism and social equity can work together to make the world a better place.

An example of someone who is doing well by doing good is Ric Geyer, my former grad school housemate, and fellow Wharton alum. Ric created a for-profit venture, Triangle Arts, that supports social change in Macon, Georgia.

HealthEdge promoted our values by promoting and sponsoring Triangle Arts and its mission at a recent Wharton Graduate School reunion program. The video and subsequent speech were intended to make people aware of social entrepreneurship and social ventures. Passionate about building strong communities, Ric has held various urban development roles in both Detroit and Atlanta.

Most recently, Ric was at the forefront of the urban exodus, moving an hour from Atlanta to Macon, Georgia, a city of about 150,000. While we have seen an increasing amount of people moving out of major urban areas to anything from mid-sized cities to small towns, COVID-19 accelerated this trend.

Recognizing that people still want a sense of community, culture, and connection, Ric’s company, Triangle Arts, brings the arts to Macon and combines with urban redevelopment to revitalize parts of the city with economically challenged populations.

Triangle Art’s mission ties directly to our mission at HealthEdge. Today, Triangle Arts Macon lifts up the voices in the community, creating an environment where people feel both safe and empowered. That uniquely aligns with our vision at HealthEdge, which is to innovate a world where healthcare can focus on people and not process.

At HealthEdge, we’re focused on promoting good health, working with our health plan customers to enable them to be more efficient so they can focus on providing access to quality care and creating healthier communities across the country.