5 Requirements for Health Plan Vendors to Achieve Payment Integrity

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.