Guide to RFP Evaluation: Payment Integrity Vendors for Health Plans

HealthEdge

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.

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