Month: June 2022

The Importance of Leading & Living with Empathy

When people feel cared for, valued, and supported, they tend to:

• Perform better
• Have stronger bonds with leadership and the organization
• Be more committed to the company’s mission

Empathy is an increasingly important skill, with particular emphasis on establishing bonds between employees, leadership, and company values. Empathy is humble curiosity. It is a skill set fundamental to emotional intelligence, resilience and building strong, trusting professional relationships. It is the ability to identify other people’s challenges and see them from their perspective.

Empathy’s Positive Impacts

A Catalyst study surveying 889 employees found empathy significantly impacts production in the following ways:

• Innovation: People who reported having empathetic leaders were 48% more likely to be innovative.
• Engagement: 76% of team members who experienced empathy from leaders reported they were more engaged at work compared to only 32% of those who experienced less empathy.
• Retention: 57% of white women and 62% of women of color said they were unlikely to leave their companies when life circumstances were respected and valued in the workplace.
• Inclusivity: 50% of workers with empathetic leaders reported their workplace as inclusive, compared with only 17% of those with less empathetic leadership.
• Work-Life Balance: When people perceived leaders as more empathetic, 86% of employees reported they were able to better navigate demands of work and life. In contrast, only 60% of people with less empathetic leadership felt this same level of competency.

Empathy is not only important for teams and leadership but also for customer interactions. Empathy better aligns us with consumer perspectives, allowing companies to better understand pain points and provide optimal solutions.

What can we do to manage teams with greater compassion and understanding to improve communication, increase productivity, and enhance team morale? Here are five tips for leaders and teammates to develop empathy within your organization.

1. Value People Not Just Deliverables

It’s common to focus on deliverables and attribute missed deadlines to individual productivity – instead of personal challenges. This establishes a void between leaders and who they lead, and staff feel less valued.

Take the time to understand what is really driving your team member’s performance or under performance.

“Empathy is about being concerned about the human being, not just about the output.” — Simon Sinek

2. Increase Active Listening

Active listening is essential to building an empathetic workplace. What are your intentions when listening? While they are talking – are you brainstorming ways to fix their problems or counteract their arguments?

Listen to understand and learn, versus listening to ‘fix’.

3. Prioritize Clear Communication

In a recent study, researchers asked a group of workers, “What do you need more of to feel like you can be your best at work?” The only consistent response was clearer communication from leaders. To achieve this:

• Provide transparency and ongoing status updates
• Clarify roles and goals for team members
• Ask how people are doing
• Have open conversations about stress and other challenging topics
• Talk about a time when you overcame a workplace challenge

4. Avoid Judgement and Assumptions

Judgements and stereotypes, impede empathy in the workplace. Avoid making assumptions about your colleagues. Give your teammates the benefit of the doubt before forming opinions.

5. Recognize Feelings

Work can be stressful. Some handle stress better than others. Be mindful of how you speak and react to colleagues. Consider their workloads, and lives outside of work. Try to always communicate with respect and kindness. You will notice that speaking with empathy is more effective.

Using Empathy to Set KPIs

When deciding your quarter or yearly initiatives it is important to leverage empathy and consider what frustrations your teams are facing. If you don’t know what barriers are for your employee’s success, ask them.

One of the most challenging parts of working in healthcare is information sharing and ever-changing policies. This may be a great starting place for empathetic KPIs.

Developing empathy in the workplace is a potent way to empower your team to perform better, have stronger bonds with the organization, and be more committed to the company mission.

There’s likely to be movement among Medicaid and Affordable Care Act (ACA) membership as the nation seems to be inching toward the end of the pandemic, at least from a regulatory standpoint.

Medicaid rolls swelled during the pandemic as relief packages guaranteed coverage for members even if they became ineligible over the course of the Public Health Emergency (PHE). But nothing lasts forever and states are bracing for an end date to the PHE, now expected to occur in mid-October. Political pressure is building to end the PHE, even as various entities plead for more time. If the PHE is not extended for another 90 days this fall, state Medicaid programs will need to begin re-verifying eligibility for members. There won’t likely be immediate disenrollment, but the process will begin and the clock will start ticking. To make things more challenging, the accuracy and success of this is likely to vary greatly according to state budgets and administrative effectiveness. There will be no coordinated, uniform approach. The U.S. Department of Health & Human Services (HHS) has promised a 60-day notice period to states before the PHE expires, so look for the administration to signal mid-August whether the PHE will renew again in October.

At the same time, the end may be in sight for the ACA subsidies legislated under the 2021 American Rescue Plan Act that served as a healthcare cushion for millions of Americans who became newly insured under the March 2021 pandemic stimulus package. The relief package specified that this support would end at the close of 2022, unless Congress acts to extend it. Some 3.4 million people could lose coverage out of a record 14.5 million ACA enrollees. The impact in terms of uninsured is a bit of a moving target, as some enrollees who are currently covered by one program may become eligible for the other. Some may have gained employer-sponsored coverage in the meantime. Either way, the task of contacting, educating, disenrolling and re-enrolling this many people will be daunting.

CMS Administrator Chiquita Brooks-LaSure said June 22 that “time is of the essence” for Congress to extend ACA subsidies in order to be ready for November Open Enrollment.

Step 2: Evaluating Payment Integrity Vendor RFPs

“Improper claims payment and fraud contribute more than $200 billion to the annual cost of U.S. healthcare…”.¹ Here’s what health plans can do to effectively partner with vendors in addressing it.

Recommendations

To achieve prospective payment integrity, health plan CIOs should:

• Issue an RFP to both current and potential partners.
• Evaluate vendor capabilities and results pertaining to:
  • Percent of claims processed correctly the first time.
  • Number of provider types and settings included.
  • Automated updates and data loads.
  • Frequency of updates.
  • Transparency of audit trail.
  • Infrastructure cost-savings.

What is the Goal of an RFP For Payment Integrity?

RFP reviews will help health plans to identify:

• Yet-to-be-leveraged advanced solution capabilities.
• Opportunities to consolidate vendors.
• Innovative approaches not previously considered.

Who should conduct the evaluation?

All business leaders responsible for payment integrity should help evaluate the RFP findings, while procurement specialists should focus on identifying opportunities to recontract existing vendor solutions.

An executive committee should be formed (see How to Achieve Claims Automation for Health Plans) which will have the final say in this analysis.

RFP Criteria

Issue your RFP to both current and prospective vendors. There is a plethora of payment integrity partners to choose from, each with varying claims processing capabilities. It is important to consider vendors that:

– Are Cloud-Based: updates and IT infrastructure can be delivered automatically to improve accuracy and decrease workflow inefficiencies.

–Address Root Causes: work as partners with payers to address root cause issues and deliver on transparency that enables payers to fix upstream issues in the payment process.

–Customize Solutions: understand your long-term vision and work iteratively with you to achieve long-term goals organization-wide.

–Offer Open API: data is centralized and accessible for more informed business decisions.

To help measure these capabilities objectively use the following chart when consulting with vendors: Following Chart

Criteria include:

• Percent of claims are processed correctly the first time. Make sure your vendor is making updates more frequently than four times a year. This allows your health plan to adapt to changing markets more effectively, remain in compliance, and pricing right the first time.
• Number of provider types and settings included. Ask about data covering all providers in every care setting to eliminate the need for multiple and disparate data sources.
• Automated updates and data loads. Ask about automatic updates to data sets and subsequent client improvement in delays and errors.
• Transparency of audit trail. Ask if there is an automated audit trail and complete archives. This eliminates the burden on the user to prove and support claims pricing results.
• Infrastructure cost-savings. Ask if the solution is cloud-based and the subsequent reduction in IT demands, costly legacy software, and maintenance clients have achieved.

How to Start Investing in Prospective Payment Integrity Solutions Today

By leveraging your dedicated committee for RFP evaluation, you’ll forge payment integrity partnerships with a thorough understanding of vendor capabilities.

Have questions about how to form your dedicated committee? (read more)

Want more information about automating claims and the impact of prospective payment integrity for health plans? (read more)

To learn more, get complimentary access to Gartner® research here.

¹Gartner®, Adopt Prospective Payment Integrity to Thwart Healthcare Fraud and Improper Claims Payment, 24 September 2020, Mandi Bishop

GARTNER® is a registered trademark and service mark of Gartner, Inc. and/or its affiliates in the U.S. and internationally and is used herein with permission. All rights reserved.

Step 1: Objectively Measure Impact of “Stacking” vs Prospective Payment Integrity

With complementary access to Gartner® research, Adopt Prospective Payment Integrity to Thwart Healthcare Fraud and Improper Claims Payment

Read Step 2: Evaluating RFPs

“Improper claims payment and fraud contribute more than $200 billion to the annual cost of U.S. healthcare…”.¹ Here’s what health plans can do to address it.

Recommendations

To achieve prospective payment integrity, health plan CIOs should:

1. Quantify the value of current “stacking” or other payment integrity efforts. Do this by establishing a comprehensive and in-depth ROI analysis, including metrics from:

• Finance
• PNM
• SIU
• Claims Leadership

2. Capture key performance indicators (KPIs). Identify methods used to achieve KPIs and how to measure success.

Who should establish objective impact? What team members should be consulted?

Implementing prospective payment solutions can be challenging because it requires buy-in from stakeholders across the health plan enterprise.

All business leaders across the enterprise who are responsible or accountable for payment integrity initiatives should be consulted when conducting an ROI analysis and KPIs. This includes professionals in:

• “IT (including reporting and analytics functions)
• Finance and actuary
• Compliance
• Claims
• Network management (including provider relationship management)
• Medical management
• Customer service (provider and member, as payment integrity affects both constituencies)
• Vendor management
• Specialty business management
• Legal
• Delegated entities”

To spearhead ROI and KPI analyses, CIOs should establish a formal committee made up of leaders in each of these departments. Gartner research states that together they should determine:

• “What are the specific objectives of the department’s payment integrity effort? For example, is the goal to open 20 new investigation cases per month or recover $5 million over 12 months?
• What types of payment integrity processes are in use to meet the objectives (that is, retrospective, prospective or preemptive) and are they delivering on their promise?
• What solution partners are assisting the department in addressing payment integrity and are they performing up to expectations?
• How does the business unit measure and report payment integrity performance and how are those metrics trending?
• Do the existing solution partners have performance requirements and incentives as part of their contracts, what are they, and are the goals being achieved?”¹

Establish Company-Wide KPIs

Once the above questions are answered, your committee should record each business unit’s specific KPIs related to payment integrity. They should also note how these KPIs are measured and achieved.

Highlight the KPIs which are:

• Uniform across business units
• Related to payment integrity goals
• Impact customer experience (cx)

Notes: Claims payment accuracy and timeliness significantly affect provider and member relationships.

Customer experience is especially important because poor provider/partner and purchaser alignment can influence revenue-generating activities, such as network contract negotiations and large group renewals. Customer experience also impacts:

• Net Promoter Score (NPS) for members and providers
• Consumer Assessment of Healthcare Providers and Systems (CAHPS) scores
• Medicare Advantage Star ratings on health plan experience measures
• Rate of grievance and appeals
• Membership churn
• Network adequacy gaps

If the payment integrity and customer experience objectives are fragmented between departments, consult with c-suite executives to define enterprise-wide corporate goals. Create a final list of goals related to KPIs that considers stakeholder responses.

Your final list of goals and related KPIs could include:

• Decrease the current claims spend
• Reduce the percentage of claims requiring rework (goal)
• Reduce the cost per claim processed (goal)
• Reduce claims-related provider call volume
• Reduce member touchpoints
• See more in the table below.

How to Start Investing in Prospective Payment Integrity Solutions Today

By developing a dedicated committee to determine cost-benefit of “stacking” strategies vs prospective payment solutions as well as establishing company-wide KPIs, you’ll overcome barriers to adoption.

The next step to payment integrity is to issue an RFP. Your committee should then evaluate current or possible vendor capabilities for improving cost avoidance as well as enhancing business and provider partnerships. (learn more)

To learn more, get complimentary access to Gartner research here.

¹Gartner, Adopt Prospective Payment Integrity to Thwart Healthcare Fraud and Improper Claims Payment, February 16, 2022

GARTNER is a registered trademark and service mark of Gartner, Inc. and/or its affiliates in the U.S. and internationally and is used herein with permission. All rights reserved.

Providers Grapple with Regulatory Realities

Providers appear to be grappling with the regulatory realities of value-based care, especially when it comes to data transparency. Although they claim that the wording of various data transparency regulations is too vague, as one example, it seems obvious that hospitals and health systems find paying fines preferable to disclosing their prices.

A recent KLAS poll of 66 revenue cycle leaders at hospitals and health systems indicated many will do only the bare minimum to comply with pricing transparency rules. Most are not doing even that much 18 months after these rules became law.

Hospitals have been required since January 1, 2021, to post cash prices and negotiated rates with payers for 300 common services. Full compliance demands that information is posted in both machine-readable files (i.e., searchable files) and is formatted in a “shoppable display,” (i.e., a consumer-friendly manner) Yet, a recent JAMA analysis found that half of hospitals don’t adhere to either standard. Fourteen percent have machine-readable files and 30 percent have a shoppable display. All told, just 6 percent of hospitals are compliant with both standards. The least compliant facilities are in highly concentrated markets and those in rural areas.

The Centers for Medicare and Medicaid Services (CMS) said June 9 they would fine a Georgia hospital system more than $1 million for violating federal transparency laws, citing the lack of a “consumer-friendly list of standard charges,” an incomplete list of services and failure to produce these within a single file. The system had been given an opportunity to correct these issues but did not do so. CMS has issued more than 350 warnings to hospitals and systems, but the Georgia fine was the first issued nationwide. Fines can reach $300 daily, but this does not appear to be a sufficient incentive, although a number of providers have changed their tune, but only after receiving corrective action plans from CMS.

Perhaps only in America does this create an entrepreneurial opportunity for companies to gather the posted information, convert it into meaningful formats and sell it back to insurers, employers and others. In a digestible format, this data can provide negotiating leverage for future contracting, so it has distinct value.

Some hospital groups have filed suit against transparency regulations, but so far the rules stand. A coalition of large employers argues the simplest way to gain compliance is to substantially raise the fines. Transparency is inevitable, even if the wheels turn slowly.

Improper claims payment and fraud contribute more than $200 billion to the annual cost of U.S. healthcare.¹

Summary

• In order to generate cost savings, most U.S. healthcare payers:
  • Focus on retrospective pay-and-chase processes.
  • “Stack” complicated and non-interoperable payment integrity solutions from multiple vendors.
• These practices generate provider and member friction, ineffective workflows and limited business transparency.
• More effective prospective solutions to prevent inaccurate claims payment are available today.
• These solutions have yet to be widely implemented due to competing stakeholder interests.
• Implementation of prospective solutions will be achieved when stakeholders align on:
  • The total impact of ineffective claims processes.
  • Clear KPIs for prospective solutions.
  • Vendor RFP evaluation.

How Big is the Payment Integrity Problem? 

According to Gartner research, 3%-7% of all commercial U.S. health plan’s paid claims dollars have payment integrity problems.

Widespread payment integrity issues have been acknowledged by political leaders like Assistant Inspector General as well as in research. Estimated improper payments by Medicare and Medicaid are expected to exceed $88 billion annually. As well, the total cost of fraud alone is estimated at over $200 billion annually.¹

In recent years payment integrity issues have only worsened. This is primarily due to COVID-19’s  underlying waivers and temporary regulatory changes for providers.

For example, Humana filed a lawsuit against telehealth company QuivvyTech for allegedly false pharmacy claims.

How have Health Plans Addressed Payment Integrity?

Today, payer CIOs support an array of payment integrity solutions. These are usually a mix of internal manual review processes and complicated vendor software.

The traditional organizational approach to payment integrity is to:

1. Pay providers without question.
2. Have both internal and external teams engage in “stacking”. (“Stacking” is retrospectively analyzing claims for inaccuracies multiple times.)
3. Chase providers for these improper payments.

Compared to a prospective approach, traditional approaches:

• Recover only a fraction of would be recovered with a prospective approach.
• Accrue significant associated administrative and reputational costs.

Instead, prospective payment solutions provide exponentially increased financial performance as well as improved provider relationships.

Why Invest in Prospective Payment Solutions Now? 

In 2022, unique market forces make prospective payment solution investment an imperative for health plan survival. This includes financial pressures due to:

• Pandemic-related coding and billing conditions
• Exceptions to medical and payment policies
• Ongoing “payvider” convergence and cross-industry acquisitions

Gartner not only is encouraging payors to adopt a prospective approach to fraud, waste and abuse management today, but has been doing so for years. In fact, prospective payment approaches were analyzed by Gartner as early as 2017, and have been included in Gartner’s Hype Cycle since 2019. and 2020.

How to Invest in Payment Solutions Today

Implementing prospective payment solutions has been challenging because it requires buy-in from stakeholders across the health plan enterprise.

CIOs should work with these stakeholders to:

1. Objectively conduct a cost-benefit analysis on current “stacking” strategies vs prospective payment solutions 
2. Issue an RFP and evaluate current or possible vendor capabilities for improving cost avoidance as well as enhancing business and provider partnerships

Learn more about how HealthEdge has been named as a Sample Vendor for Prospective Payment Integrity (PPI) solutions in the Gartner Hype Cycle for U.S. Healthcare Payers, 2022.

¹Gartner, Adopt Prospective Payment Integrity to Thwart Healthcare Fraud and Improper Claims Payment, February 16, 2022

GARTNER is a registered trademark and service mark of Gartner, Inc. and/or its affiliates in the U.S. and internationally and is used herein with permission. All rights reserved.