Shifting Trends in Healthcare Payments: A Focus on Prospective Payment Integrity
Lately, payers have been making some interesting shifts to better meet their organizational goals such as executing transactions more quickly and identifying root causes of incorrect payments. As member and customer expectations continue to increase in these areas, such as expecting prepay instead of postpay organizations are taking action to address new internal and external pressures.
In the IDC Spotlight: Prospective Payment Integrity: Moving from “Pay and Chase” to Predictive report, 7 key industry trends which positively impact payer challenges were identified:
- Advancements in Internal Workflow Solutions – Internal workflow solutions are being improved by bringing together different components to streamline efforts. Consolidation of the vendor solutions/IT stack translates to less internal lift for payer organizations.
- Optimized Ecosystem – Externally interoperable solutions with best-of-breed content and functionality are being acquired, allowing payers can optimize their ecosystem of solutions. Improved workflows externally improve automation so internal efforts can focus elsewhere (e.g., expanding into new LOBs, improving member and provider satisfaction).
- Vendor Alignment – Payment integrity vendors are aligning and merging to accelerate a “technology push” for various organizations and functions to work together.
- Claims Digitization – Advancements in claims digitization and adjustment automation are being made to support payment integrity in core administrative processing systems (CAPS). Over 20% of all claims are submitted as physical copies and require high amounts of manual labor to process, drastically increasing costs, errors, and processing time, and leading to potential risks to an organization.
- Transparency through Open APIs – Payment integrity solutions designed for transparency can work to consolidate and coordinate sound, useful data through open APIs. Centralizing data can help payers understand root issues, make informed business decisions, and effectively communicate with and educate their provider network.
- Improving Coordination of Benefits (COB) – On average, it takes a plan nearly 5x times longer to settle a COB claim than a regular claim. Improving the coordination of benefits that apply to a person who is covered by more than one health plan has the potential for significant time savings for payer organizations.
- Administrative Audits as a Tool for Improvement – Organizations are applying administrative audits to medical claims that are complicated and costly if not managed correctly. A claim audit of any kind can identify root causes of errors, find methods for improvement and ensure compliance.
To learn more about key trends in healthcare payments and enhanced processes payers are leveraging, including the application of analytics and coordination of workflows, you can read IDC Spotlight: Prospective Payment Integrity: Moving from “Pay and Chase” to Predictive.