Payment Integrity: Can We Get It Right?

Payers are investing in Payment Integrity practices 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?

Choosing a Long-Term Partner for Growth and Success

Change is a constant in the healthcare market. So, when healthcare payers are evaluating new technology investments, it’s imperative that they look beyond deploying a quick fix and seek out solution providers that care about—and can accommodate— your long-term transformation goals. Solution providers that challenge the status-quo, focus on functional design, and continuously reinvest in their products ensure that their solutions go beyond addressing your immediate needs to deliver partnerships for proactive change.

An internal culture that challenges the status quo

Technology solutions are ultimately a reflection of the people that build them. Organizations that encourage an internal culture of questioning the way things work is important. Not only does this mindset foster a sense of excitement, but it also helps employees seek out answers to the question, “how can this be better?” Much of today’s healthcare technology remains focused on short-term solutions that are not designed to adapt. But an internal culture that not only tolerates, but encourages questioning, breaking, re-building, and pushing the boundaries will continuously evolve—and this will show in their products.

Focused on functional design

While several providers may be able to offer a solution that meets your needs, many are limited to niche functions and require additional solutions or workarounds to accommodate the intricacies of your unique workflow. These cobbled-together solutions and processes complicate the claims payment ecosystem, creating manual rework and IT drag, ultimately leading to disjointed activities that result in inaccuracies and waste. This approach, however, is far less effective than using a system that is thoughtfully designed to allow all processes to work together seamlessly, eliminating all errors and delays.

Companies that are focused on design consider the ever-evolving nature of your claims payment ecosystem and build products that can adapt and grow with you. Cloud-based, interoperable, extensible solutions with open APIs are designed to deliver synchronization of payment guidance. These foundational capabilities, in turn, increase automation, reduce IT lift, and enable more rapid innovation to accommodate market needs.

Reinvestment in the products they build

An organization that continuously reinvests in its solution and prioritizes the build-out of features, capabilities, and support for its clients is a sign that they can provide a successful long-term partnership. Solution providers that understand the ever-evolving demands on payers will create a road map that considers immediate client needs while also anticipating future needs, like increased AI and machine learning capabilities. Their solutions are designed to grow and remain agile as new functionalities and content are developed. Furthermore, SaaS solutions that can deliver these updates via the cloud with minimal internal IT lift enable health plans to focus on other efforts instead of maintaining their technology solutions. As demand for transparency grows, organizations that invest in interoperability will ensure payers have insight into all aspects of their claims payment processes.

Choosing the right technology partner ensures long-term success for payers while enabling easy upgrades, interoperability, and automation—all without demanding additional lift from your internal IT. When you partner with innovative providers, they will help shine a light on the path for your organization—instead of holding you back, they will guide you, continuously, towards growth, agility, and not just accommodating, but anticipating an ever-evolving market.