Many payers face profitability declines while also taking in a huge influx of newly insured members whose risk profiles are unknown. Payers continue to see billions of dollars in error rates on claims each year, and fraud and other abuse further erode the bottom line.
So what can payers do to shrink the risk and increase revenue? By elevating attention to siloed operations (such as subrogation, COB, eligibility, claims analytics, and others) and taking a strategic and holistic approach to the payment integrity challenges that all payers face, millions of dollars can be translated into funding to support the initial cost of entry into new markets and to mitigate the risk of new ventures. Payers should be paying a claim the right way the first time, and avoiding errors in the first place.
Analyze payment integrity processes and performance holistically
When a health plan elevates its view of payment integrity programs to an enterprise level, it can find ways to leverage resources, processes, technology, and data across departments in ways that can yield huge returns – tens of millions of dollars in savings and additional recoveries. A comprehensive and deep analysis of payment integrity program results is needed to determine how and where a plan can make important improvements.
It is important for payers to look at all areas of their programs: Is cost avoidance being maximized? How do their results compare to similarly sized plans? Are outsourced vendors providing optimum value? Is current eligibility data making its way to other systems and departments? If there is a problem in one area, is there a process to fix it at its source? Is the right technology in place? These are just a few of the questions payers should consider.
Align workloads with the right people
Payers can also find opportunities to recover more by optimizing their best assets -- internal staff and external vendors. This doesn't mean looking for ways to eliminate. This means making sure that it is known where the best recovery results are coming from and that recovery efforts are aligned with staff and vendors' strengths. At some plans, the internal COB team can recover more dollars at less cost than any vendor.
Get the data right
Inconsistent or incorrect eligibility data is often at the center of payment integrity problems. That's not surprising when you consider that provider data and member eligibility data is captured at multiple points and managed by disparate departments within the organization. As a result, it's often inconsistent, outdated, or wrong and leads to improper claims payments. By making data clean, transparent and accessible enterprise-wide, payers have the ability to process claims right the first time and reduce recovery cost increases, often to the tune of millions of dollars saved.
Adopt appropriate technology
Improving payment integrity processes often leads to a technology discussion. One key benefit of new payment integrity-specific applications is automation. Automating workflow across multiple tools, departments, and databases, while simultaneously being able to upload eligibility and claims data into a payment integrity tool, is one of the most efficient ways to improve outcomes.
New tools and technologies that allow for complex data mining and matching in the case identification process often improve case management workflow by walking internal staff and vendors step-by-step through the process. Much of this work becomes automatically assigned vs. manually assigned and makes the handoff more efficient, less manual, and easier to validate because it has been tracked and reported.
Paul Vosters is the president and COO of Discovery Health Partners.