Health plans transforming their business models to accommodate new markets and new lines of business may also experience a strain on their payment integrity programs. This strain can create membership fluctuations, business complexities and regulatory mandates across all areas of claims processing. Without a vigorous payment integrity strategy, these pressures can create competing or misaligned objectives across the claims process continuum and lead to more manual interventions that increase both provider abrasion and cost.
Resolving incorrect payments long after claims are received is a labor-intensive process that costs the health system billions. By developing and committing to an enterprise payment integrity strategy, health plans can improve accuracy, lower costs and improve provider satisfaction.
Although public and private exchanges provide an opportunity to expand lines of business, the associated membership flux can result in additional claims payment issues — requiring an increased focus by payers on a proactive, prepayment approach.
The typical payment integrity approach has:
- Focused on retrospective pay and chase
- Lacked unified, enterprise-level reporting
- Created competing objectives across claim processing departments
- Caused provider and member friction around payments
- Increased administrative and medical costs, potentially impacting medical loss rations (MLRs)
Bringing payment integrity into focus
Proactive payment integrity is a strategic opportunity to position health plans for better financial strength in the future, and compete in today’s consumer-focused market. An important first step to make payment integrity a strategic imperative is to identify an executive sponsor who can help socialize the concept, and define organizational philosophical components and program components that include:
Developing key performance indicators (KPIs) that can help you measure effectiveness is also critical to determine how well your strategy is working.
Payment integrity best practices
There are seven best practices essential to developing a well-coordinated enterprise payment integrity strategy that helps to reduce costs and unnecessary provider abrasion.
Our white paper provides an in-depth review of these seven practices, but some of the recommendations include:
- Shift from post-payment identification and recovery to pre-payment avoidance–to reduce provider abrasion–while decreasing costs across the entire system.
- Consolidate vendors to increase efficiency and reduce multiple vendors going after the same providers–to avoid friction.
- Conduct regular self-assessments to identify gaps in enterprise payment integrity capabilities–to establish a “best practice comparison.”
Download our white paper, “Maximize savings with an enterprise payment integrity strategy,” for more insight into improving enhanced payment integrity efforts.
About the author
Steve Yurjevich, senior vice president and general manager, Payment Integrity, has been with Optum for six years through the acquisition of AIM Healthcare, a nationwide payment integrity player, where Steve held several roles as vice president of Operations for over eight years. Prior to that, Steve worked in CSC Healthcare’s consulting division working with payers on claims payment system modernization and management consulting.