Healthcare payers have made great strides to improve claims errors and drive down costs. The AMA's 2013 National Health Insurer Report Card recently found a significant reduction in the claims error rate to an average of seven percent among the nation's largest commercial health insurers. But there is still work to do.
Even a seven percent error rate leads to billions of dollars in waste. And while legislative mandates such as health insurance exchanges, electronic health records, and ICD-10, promise to introduce many improvements to the system, they bring along the potential for increased errors – and increased costs.
Whether your organization is focused on further driving down costs or minimizing the risk associated with regulatory mandates, now is an ideal time to fortify your cost containment programs with improved processes, modern tools, and a focused, expert staff.
1. Identify claims aberrations faster and more accurately with a data-driven cost containment application
You might be surprised by how many hidden opportunities to save or recover claims payments are lurking in your files. A data-driven, cost containment-specific application can help you find them. Look for a technology that uses data mining and logic to rapidly analyze claims and eligibility data against thousands of diagnostics codes to find potential problems. These features can point out patterns and trends across patients and providers and apply the learning across your membership to accurately identify more opportunities to recover. As an added bonus, newer applications are easy to use and offer a single point of entry for multiple functions (ie COB and subrogation).
2. Improve transparency with an automated workflow or case management tool
Automated workflow, which often is included as part of newer cost containment applications, helps you manage cases more efficiently and recover faster. It gives you the ability to electronically manage cases from identification through recovery and creates transparency across your full inventory and each individual case. With all case-relevant information easily available to recovery teams, you can say good-bye to flip-flop claims – corrected claims that keep coming back. Automated workflow applies corrections at all points along the claim lifecycle, so once they get fixed, they don't pop up again.
3. Access new technology cost-effectively with cloud applications
Now that I've mentioned new technologies twice, let me alleviate your fears of expensive software and hardware, long implementation cycles, and intensive training. Many applications are available "as a service," (via the cloud) meaning you access the application online and pay on a subscription basis. They are cost-effective, user friendly, and most importantly – secure. The ability to deploy these capabilities within a few months means you'll start saving and recovering faster.
4. Reduce downstream problems when you get eligibility right from the start
Sorting out eligibility information greatly improves the ability to pay claims correctly in the first place when they are presented, which ultimately saves lots of time and money. Consider the fluid nature of member information and the wide variety of sources that capture and manage eligibility data. It changes constantly and it's collected by different departments at different points in time, which can result in inconsistent eligibility data across the company.
There are technologies that can help payers turn this into an ongoing, real-time, automated process that integrates and standardizes eligibility data from multiple data sets and provides access for downstream applications. Again, you can access this capability via cloud technologies to reduce implementation time and cost.
5. Assemble a dedicated team supported by your technology
Cost containment covers a variety of functions – coordination of benefits, subrogation, MSP validation, and eligibility to name a few. To maximize cost savings and recoveries in these areas requires specialists who are trained and experienced in each capacity. With deep knowledge of the systems, the regulations, and the nuances of their specialty, your resources can enhance processes to more efficiently and thoroughly pursue recoveries and savings opportunities. With the increased savings, they can pay for themselves fairly quickly. Some payers short change these programs – and their outcomes – when teams do double duty across claims and COB, for example. If you can't invest in dedicated resources, they can be outsourced.
6. Look at the big picture
It's rare that a single department can see across the whole organization and grasp the big-picture of cost containment or payment integrity. Data crosses departments and opportunities to avoid or recover costs are spread throughout the organization. For example, the COB department might validate information, but that never makes it over to where the claim is paid. In the end, the organization never realizes the full benefit of that data. Company stakeholders who have an interest in the integrity of the data and the implications it has on the bottom line need to come together. When you take a quick glance at groups that might be involved (finance, risk, etc.) you can see that organizationally this could be a difficult task, but worth the effort.
Paul Vosters is the president and COO of Discovery Health Partners.