By: Erin Schmuker, Vice President, Product Solutions – Payment Integrity, Optum
This is the 1st blog of our 2 part series “Maximizing post-payment recovery, preparing for pre-payment success”
There is an increasing focus on pre-payment. However, your organization may not be able to fully commit to a comprehensive payment integrity approach. Even the most robust payment avoidance strategies also rely on post-payment savings from a strong back-end recovery and detection program. So as you continue to form your pre-payment strategy, consider how you can yield even more from your post-payment efforts.
This blog series explores how you can optimize your payment integrity recovery gains while building the foundation for significant pre-payment success.
What can we do to maximize our post-payment strategy?
Start with a self-assessment to establish clear, quantifiable success criteria. This enables you to measure all performance aspects of your enterprise payment integrity process. For example:
- Look at the actual dollars you are recovering today.
- Examine the impact those efforts have on your provider network and their satisfaction.
- Benchmark how your performance compares to industry standards.
This assessment will help drive an effective recovery program. While it is important to identify and investigate as many potential errors as you can, if you can’t recover them in a way that is not disruptive to your network, your program quickly becomes ineffective.
What else makes up a post-payment assessment?
Compliance is an important part of your initial steps. This is a key area of focus even for a payment integrity program that is not fully mature. With regard to fraud and abuse, how do you identify fraudulent providers and keep them out of the system? And, again, what’s your process for understanding the effect of your efforts on providers and gaining buy in? It takes regular touch points with the network staff, including surveys conducted at least annually.
Once you have that regular cadence in place, you can identify trends and put action plans in place. This includes partnering with key vendors to help you make changes to advance your recovery success. But it all starts with that initial self-assessment. In addition, strengthening your network relationships will also help you prepare for pre-payment.
Can we do this level of assessment on our own?
Yes, although a trusted partner makes management and assessment of payment integrity much easier. Consider the increasing pressure you and other payers are under to transform operations, support new business models, implement value-based reimbursement programs and constantly find new ways to reduce administrative and medical costs. To thrive in this intense environment, you have to have modern technology, a nimble business model and advanced analytics. But the cost of recruiting and training the talent to power a high-functioning payment integrity program, as well as identifying and implementing the technology to drive it, can far outweigh the value of partnering with a service provider.
In addition, a trusted partner is likely in a better position to provide relevant benchmarking to help you determine how you compare, and work with you to set realistic goals for improvement.
What should we look for in a partner?
The ideal partner should offer comprehensive analytics, consulting and both software- and service-driven solutions. Because you will shift the responsibility of reporting to the partner, they must have dashboard-style analytics and the ability to provide ongoing measurement of key metrics. It’s also important to select a partner that is motivated to address your pre-payment opportunities and be capable of setting you up for success for comprehensive payment integrity.
How important are analytics?
Integrated analytics are essential to a health plan’s ability to glean insights. To get the most out of the insights, the analytics need to create a consistent feedback loop between post-payment and pre-payment analytic results. Your partner should be able to develop that feedback loop to give you a full line of sight into all the analytics. In fact, this is one of the first steps you want to take to create a strong foundation for pre-payment success.
Learn more about analytics and other ways to make the transition to pre-payment, as you take action to maximize your post-payment recovery.
Watch the video: Vital steps to optimizing payment integrity
Connect with Optum to explore the value of a comprehensive payment integrity strategy
About the Author:
Erin Schmuker is responsible for product development and operational execution for Optum post-payment services solutions. She leads an organization that delivers more than $500M in savings annually to health plans nationwide.
Erin has been in the payment integrity arena for more than 15 years with significant expertise on payer/provider collaboration and retrospective claims analysis. Erin’s division at Optum is continually seeking opportunities to develop services and solutions that help health plans solve the complex problems existing within their payment cycle today.