Category: Uncategorized

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.

How health plan leaders can maximize productivity without burnout.

Why Resilience Matters 

Think about the last time your health plan faced a large change, planned or unplanned. This may have been a merger/acquisition, departure of a longtime CEO, or the reorganization of a department.

Other common changes include:

• Updating a company mission
• Introducing a new technology
• Employee training and development of a new skills
• New hires
• New roles or responsibilities
• New customer communication issues
• Losing a great employee

How quickly did your teams adjust to the change? What feelings came up for workers? Did they meet new challenges with enthusiasm or frustration?

Leadership promotes resilience by connecting people to purpose, accomplishment, and one another.

When this is achieved, companies have experienced:

• 10x more likely of a thriving culture
• 7.5x greater odds of employees easily adapting to change
• 88% reduction in employee experiencing burnout

What do resilient teams look like in action? 

Resilient health plan teams implement changes rapidly with minimal resistance. Although there are learning curves with any updates, like time spent adjusting to a new software, resilient teams are invested in change and assured of its value.

Even if changes are difficult, resilient teams continue to show up to work energized, ready to enhance patient and provider loyalty and experiences.

Resilient teams experience organizational effectiveness where productivity skyrockets due to aligned motivations and empowered people.

Necessary claims rework is energetically tackled, thoughtful and trusting mentorship occurs, and all teams are ready and willing to help within matrixed organizations.

So how do you achieve a resilient workforce?

Six Elements of Resilience 

Over a period of 6 months outline and score criteria in each of the 6 elements of resilience to track your progress toward achieving a resilient team.

1. Growth 

Growth enables and encourages employees to invest in their learning. This can be learning related to their current position and role, or perhaps interests laterally related to their current role. It is as simple as asking what they need to grow and develop in their role.

For example, does your organization think beyond formal training by considering starting a book club where employees can discuss the latest trend in your industry. Or provide a mentor/mentee program to help create healthier, happier, and more productive workplaces.

The top-three “soft skills” your employees need include problem solving, emotional control and purpose. Executives consider these skills to foster employee retention, improve leadership and build meaningful culture. The good news is each of these skills can be learned by your employees.

Enrichment and empowerment for growth opportunities is essential to resilience.

2. Health 

To face challenges enthusiastically, your team must be well-rested and healthy. Mental health and emotional wellbeing allow your employees to think through complex problems and communicate effectively with a higher tolerance for frustrations or adversity.

It’s important to teach employees how to manage their stress levels and effectively respond to pressure. For instance, some employees may need a 5 minute break if feeling stressed during a project. After the 5 minutes they can return to the work refreshed and more effective at tackling the problem.

For others, running or a hobby, even talking to loved ones during after work hours, may allow them to show up to work energized and refreshed.

As a leader, make sure you understand what makes your employees show up as their best selves. Check in with them about those activities.

Leading with empathy increases trust, creates positive work relationships, and increases collaboration.

Don’t know what activities help an employee feel refreshed when coming to work? Just ask! Odds are most people know this already about themselves and would be happy to share this information with you. They may even be excited to hear you care.

3. Purpose 

It’s important to understand what motivates your employees. At a minimum, each team member should be driven by the company’s impact or mission statement. As a leader, make sure you understand all roles comprehensively. This may require you to shadow or actually do different jobs for a day. 

When faced with adversity, remind your team about the ROI of their efforts to the company mission and to their personal incentives. Make sure during quarterly meetings you tie individual and team KPIs back to your organization’s mission.

Remind your team how their work has meaning and in what ways it affects the customer.

4. Communication

Relationships matter.

In order to understand the motivations of your employees and help promote their wellbeing you must be able to communicate effectively.

More important than offering tips, advice or feedback, is the ability to deeply listen. Although you are not expected to be a counselor or therapist, you should be able to provide assistance and point employees to appropriate resources.

Everyone has a unique preferred communication style. Make sure you know the most effective methods to talk with each employee. (And if you don’t know someone’s preferred method- just ask!).

Schedule time to talk with each employee. Take this time to understand their unique motivations and goals. Support them in their efforts and provide motivation when they hit obstacles like having run a poor meeting or having difficulty getting buy-in for a new technology.

5. Change Management 

Although we would love to read this article and by the end our team magically becomes the epitome of resilience, this is likely not the case.

Make sure you are meeting your employees where they are at. Don’t try to forcefully impose your views or positive mindset about changes. Make sure you accurately gauge the reception of the new updates and manage related emotions.  A great way to empower teams is to create small wins and celebrate those successes.

Change takes time. Behaviors take about seven weeks to become habits. Over communicating by continually reminding employees of changes is needed throughout the first two months of change.

In addition, make yourself approachable. You should provide safe spaces to ask questions.

6. Collaboration 

“Leaders think about collaboration too narrowly: as a value to cultivate but not a skill to teach”- Francesca Gino, Behavioral Scientist, Professor, Harvard Business School

To promote collaboration, write down the 6 collaboration tips below. Put them somewhere visible in your office. Read them at least once a day to remind yourself of collaboration goals.

1. Teach People to Listen, not talk
2. Train people to practice empathy
3. Make people more comfortable with feedback
4. Teach people to lead and follow
5. Speak with clarity and avoid abstractions
6. Train people to have win-win interactions

Other Helpful Resources

• Stress and Resilience Resources
• Burnout Prevention and Treatment
• National Suicide Prevention Lifeline 1-800-273-8255 available 24/7
• Creating a Team That No One Wants to Leave
• Find your Calm by creating a free account on http://calm.com

Standard Manual Processes and Disjointed Tech Stacks Combat Payment Integrity

Traditionally, payer’s internal IT and business operations have implemented government updates and/or third-party software updates to ensure compliance.

Remember those daily CMS transmittals?

Executing a change process internally can range from 3 weeks to 6+ months depending upon the organization and details of the update. Even when efficient, this timeline still allows for errors to be made in claims payment. When errors occur due to untimely updates, time consuming rework is required in addition to potential fees and penalties for non-compliance. A reasonable window for updates, based on the frequency of compliance changes, is 2 weeks.

Single Interoperable SaaS Solutions Promote Payment Integrity

Subscribing to a Software-as-a-Service (SaaS) delivery model is a more efficient basis for handling recurrent changes. SaaS is a delivery model in which software is licensed on a subscription basis and is centrally hosted in a secure data center. It is the most promising solution for reducing costs for internal IT resources and supporting scalability of computer resources “up” or “down” to match business demand.

When using a SaaS delivery model, automatic and frequent updates can lessen the burden of several internal teams while also promoting a culture of paying correctly the first time instead of chasing down inaccuracies at a later date.

According to a report by Grand View Research, “the global healthcare software as a service market is expected to grow at a compound annual growth rate of 19.5% from 2021 to 2028 to reach USD 51.7 billion by 2028.”

Requirement 1: Timely Updates

Ask Vendors:

• How frequently is your library automatically updated? 
• Does it require any effort or time from our internal teams?
• Are there different pricing tiers related to frequency of updates?

SaaS providers can deliver ever-evolving CMS updates virtually “just in time” versus the months spent waiting for implementation in-house. It is possible for organizations to dramatically increase first pass claims payment accuracy with constant CMS compliance though the use of a SaaS model.

However, the industry needs to be wary of SaaS solutions from vendors whose software and internal Software Development Life Cycle (SDLC) are not designed for rapid change and scalability.

Often, these third parties will “host” their legacy or installed software and advertise SaaS delivery models. A hosted solution may alleviate health insurers’ IT burden; however, the claims adjudication process may still be subject to slow software update cycles. Infrequent updates can limit performance and keep payers in the cycle of inaccuracy.

Requirement 2: Workflow Efficiencies

Before a Demo: Draw up a flowchart with your claims specialists of current processes. During a demo continually evaluate how the software will fit into workflows and ask strategic questions about customizability.

The right SaaS solution can also provide workflow efficiencies to enhance core claims systems. Something as basic as claim routing information in addition to the “claim price,” can help insurers avoid inappropriate adjudication and high pended claims counts.

Integrating the claims system with a SaaS model through a variety of industry accepted technologies like Web Services enables meaningful information to be efficiently returned to claims systems.

Make sure your vendor partner offers customized features and transparency to fit into your unique workflow. Both customization and transparency are important when it comes to setup and keeping your workflow running efficiently.

Requirement 3: Robust Features

When Vetting Vendors: Create a checklist with each of the below 5 features to ensure your partner is offering a comprehensive technology.

Make sure your vendor offers the following features:

1. Medicare, Medicaid and other government program fee schedules and policies in production prior to their effective dates – so that operational and financial impacts can be analyzed and managed
2. Negotiated reimbursement terms with providers configured accurately in the core claim system or third-party systems 
3. Automation of claims payment maximized, avoiding the costs of manual rework and manual errors
4. The ability to retroactively modify claims payments
5. The ability to analyze areas of current or potential waste – analytics and decision support – as the basis for new payment related practices

Requirement 4: Intuitive Design

Ask Previous or Current Clients: How long did it take for your team to learn the interface? What does the training time look like for new employees? Does the vendor offer any resources or support?

A well-designed system can serve payment integrity and end user needs quicker and more affordably than heavily promoted, cobbled-together alternatives. This also allows for interoperability and solutioning in one place rather than across vendors.

Maintaining transparency and continued progress after implementation is crucial to continued success. Vendor partners should continue to be intuitive and modern by consequently making design updates.

Requirement 5: Cultural Alignment

Before Calls with Vendors: Assess your company’s strengths and weaknesses to help determine what type of partner and solution is needed.

Keeping your analysis process one-dimensional may lead you to a partner that has the right solution, but the wrong culture to adequately provide day-to-day improvements to your business.

It’s imperative to eliminate the fear, uncertainty, and doubt (FUD) that often clouds judgment and drives organizations to the perceived “safe” choices when those choices may not be optimal, more cost-effective, or efficient. Establishing and weighing business requirements for long-term partnerships helps health plans score each vendor objectively and counteract FUD.

A vendor as a partner should take the initiative to listen and absorb feedback to ensure you feel supported by cultural alignment now and in the future.

How to Use These Requirements to Vet Vendors

Before beginning discussions with or researching vendors, health plans must first understand the unique core features needed for a successful partnership with their firm. The above 5 criteria can help health plans organize a comprehensive list of requirements from vendors and then objectively score each solution according to their unique needs.

Learn more about how SaaS solutions empower health plans to achieve payment integrity here.

Summary

Automated claims technologies are uniquely positioned to increase accuracy of claims because:

• Most claims paid by health insurers are based on predetermined rates
• Medicare and Medicaid policies change frequently

Pricing Accuracy is a Blue-Chip Item

Pricing accuracy is a continual concern due to:

• Today’s fee-for-service (FFS) claims processing landscape
• Frequent disputes and time-based fees or penalties from inaccurate claims
• Continued expansion of data sources such as:
• Claims
• Encounters
• Enrollment forms

Claims, encounters, and enrollment forms all need to be reconciled to accurately pay fee-for-value (FFV) methodologies like the payment bundles and shared savings programs being implemented nationwide.

Inaccurate Claims Lead to Disputes and Time-Based Fees or Penalties

Millions of identified underpaid or overpaid dollars are waiting to be reclaimed by the overpaying payer or the underpaid provider, creating disputes and time-based fees and penalties.

What makes these inaccurate claims (that increases claims management risks) so prevalent?

Updates are impossible to keep up with using standard practices.

These standard practices include relying on disjoined technologies or SMEs to manually establish library changes. Disjointed technologies update content libraries sparsely and fail to do so as a single system. Manual changes by SMEs are time-consuming and impossible to do profitably while staying in compliance.

Both lead to claim errors and rework.

Effectively and profitably accommodating daily updates to policies, methodologies, and rates will instead require investment in single interoperable automation technologies.

Medicare and Medicaid Experience Policy Changes Almost Daily

Centers for Medicaid and Medicare Services (CMS) publishes daily transmittals to communicate new or altered policies, rates, and other specific modifications. These can include retroactive changes to claims payment rules dating back months or even years. On average, using standard methods, libraries are updated every quarter, a far cry from the daily needed updates to stay compliant and avoid rework.

With a comprehensive and interoperable automatic claims technology, policy changes are updated at least every two weeks – saving health plans costly and complex rework on millions of claims.

Most Claims Are Based on Predetermined Rates

Commercial in- and out-of-network payment arrangements are often based on predetermined Medicare payment methodologies like:

• RBRVS
• MS-DRGs
• APCs
• Other prospective payment baselines like third-party case-mix groupers

The complexity of these payments partnered with standard practices like manual entry and disjointed technologies, lead to millions of errors in pricing.

Automating these complex claims with a single interoperable technology solution is the only proven effective method for eliminating these errors.

How Address Claims Payment Accuracy

To optimize payment accuracy, health plans are slated to invest in interoperable, customizable claims automation technology.

Vendors should be screened for ability to integrate into current workflows, comprehensiveness of training and strategic business alignment.

Learn more about claims payment accuracy or how to find the right technology vendor here.