Payment integrity emerging as a top cost reduction opportunity for health plans

As cost reduction continues to take center stage in healthcare, payment integrity is in the spotlight. Increasingly, health plan executives are recognizing the power of payment integrity functions to add significant value to a health plan’s bottom line by improving the plan’s ability to recover or avoid improper claims payments and improve accuracy of premium

Trends in healthcare coordination of benefits

A changing environment drives the reevaluation of current COB practices   Healthcare coordination of benefits (COB) has been a relatively unchanged process in health plans for many years, but advances in data management, analytics, cloud-based software, and digital communications are causing some interesting trends to take shape in the COB world.  These technologies, which have

Delivering quality service to health plans without the babysitting

Maintaining a high level of customer service and solution quality is challenging in any industry.  And because our customers are in the highly-regulated market of healthcare and health insurance products, the services and outcomes we provide are under almost as much scrutiny as the plans we serve.

Modern population risk management: Initiatives and transformation

It is an exciting and challenging time to be a part of a health plan right now. New pressures, challenges, and opportunities are hurtling at plans from all directions in the form of providing services with value over volume, actively engaging consumers, and mandates that require a higher level of risk and quality management.

Subrogation recoveries for Medicare Advantage plans

This topic has been evolving for more than 10 years as litigation and case law have disputed over the issue of whether the private cause of action for double damages under the Medicare Secondary Payer (“MSP”) Act provides Medicare Advantage (“MA”) Plans with the right to bring suit against primary payers.

It’s the perfect time to evaluate your payment integrity technology

For many health plans, payment integrity is able to influence the bottom line in powerful ways. For payment integrity organizations (sometimes called cost containment), the new year is the perfect time to evaluate what has been working well and what can be done better and more efficiently.

Post-conference wrapup: 2015 NASP Conference

(Michele Stuart of JAG Investigations') presentation was alarming and fascinating as she showed us how vulnerable our social media activity makes us to criminal activity and walked us through steps we can take to protect ourselves.

Transforming payment integrity with transparency

As the healthcare industry continues to transform, it has become clear that the need for increased transparency is one of the critical drivers of change. Health plans are being asked to share more information with a broad range of stakeholders in an effort to control costs and drive improvements in efficiency.

An enterprise approach to payment integrity technology

For many health plans, payment integrity is able to influence the bottom line in powerful ways. For payment integrity organizations (sometimes called cost containment), the new year is the perfect time to evaluate what has been working well and what can be done better and more efficiently. And often payment integrity technology is one of

Eligibility data management: Fixing payment integrity at the source

With all of the demands on your team, your time, and your resources, eligibility data management may not be your first priority. In our experience with over 15 health plans, eligibility data issues are the root cause of between 20% and 30% of payment integrity costs.

The right eligibility data management solution

Addressing eligibility data management can seem like an overwhelming or impossible task among all of your other competing priorities. However, fixing these data errors can eliminate downstream impacts to your payment integrity programs that are likely costing your plan millions of dollars.

The eligibility impact: how and why eligibility data issues affect payment integrity

Over the last two months, we’ve examined how organizational and technology structures can keep health plans from recognizing, understanding, and resolving their payment integrity challenges. This month, we want to spend a little time examining one thing that can be at the root cause of some of those challenges: eligibility. Eligibility issues impact a multitude

Lack of information transparency and benchmarks hampers the payment integrity organization

By Bill Whittemore, vice president of Ajilitee, Discovery Health Partners’ sister division   In my last blog post,  I discussed some of the challenges healthcare payers face related to their lack of transparency into recovery performance results at a program level. In this post, I’d like to dive deeper into the problems caused by lack of

Silos and insufficient technology challenge the payment integrity organization

By Bill Whittemore, vice president of Ajilitee, Discovery Health Partners’ sister division   Several months ago, I wrote a blog post discussing the challenges that cause health plans to lose money on their claims payment integrity programs. In this post, I’d like to dive deeper into the problems caused by insufficient technology and dispersed payment integrity

Organizational complexity within health plans leads to claims payment integrity challenges

  In their ongoing efforts to manage costs and improve profits, many health plans are turning to the area of claims payment integrity, where plans are finding opportunities to reduce annual claims expense by millions of dollars. Despite the compelling business case for payment integrity, many health plans find that organizational challenges often mask these

The real cost of the payment integrity challenge

Clearly healthcare is the most interesting and dynamic sector in the U.S. today. We are witness to an unprecedented transformation as healthcare stakeholders embrace new delivery entities and new reimbursement models, shift attention to building relationships with members, and explore new markets. There will be winners and losers in this game, and everyone is placing

Maximizing your mass tort recoveries

Joint replacement surgery is fairly common in the United States, with more than 285,000 hip replacement surgeries every year[1]. However, if that new hip turns out to be defective—causing further pain or weakening of the joints—this routine hospital procedure could become subject to the complexities of mass tort litigation. What is mass tort? Mass tort

Next-generation subrogation solutions: measuring your subrogation solutions

As the old saying goes, “You can’t improve what you don’t measure.” Imagine you are a student taking a test and never knowing your grade. It’s nearly impossible to strategize a plan for improvement if you are unaware of your current performance. This same principle applies to subrogation cases. Analytics are essential to evaluating the

Next-generation subrogation solutions: optimizing your subrogation solutions

Once you have identified which subrogation cases have recovery potential and which do not, it’s time to make sure you are optimizing program performance in three key areas: Platform – leveraging technology and automation to improve results Process – evaluating recovery workflows to ensure efficiency is maximized by leveraging available technology People – recruiting and

Next-generation subrogation solutions: identifying subrogation opportunities

No one wants to leave money on the table. But that’s often what happens when health plans don’t recover payments for claims that are someone else’s financial responsibility. A health plan’s successful recovery of injury-related claims depends upon a fine-tuned and optimized subrogation process. In our three-part series, “Next-generation subrogation solutions,” we offer effective strategies

Four Important Reasons to Address Rx with MSP

By now, you’ve discovered how valuable it can be for Medicare Advantage (MA) health plans to validate and correct member records to restore underpaid premiums due to Medicare Secondary Payer (MSP). Many MA plans, however, overlook the necessity to address Prescription Drug (Part D) open records with MSP. Here are four important reasons to address Prescription

Underpaid MSP premiums: How much are they costing you?

When it comes to premiums, many Medicare Advantage (MA) plans are being underpaid because of incorrect Medicare Secondary Payer (MSP) adjustments. It’s a known problem – Commercial plans mandatory Section 111 reporting creates instances of other coverage for a member. This flags the MA plan as the secondary payer for that member resulting in a negative

How transparent are your recovery operations?

Assess the transparency of your recovery programs conducted in-house or by vendors.   This self-evaluation tool will help you determine “the transparency factor” in your initiatives.    Take our Transparency Assessment Survey to learn more.                                          

Discovery in Depth: a payment integrity blog for healthcare payers

Healthcare payment integrity: the process of ensuring that a health claim is paid correctly—by the responsible party, for eligible members, according to contractual terms, not in error or duplicate, and free of wasteful or abusive practices.  Payment integrity uses data mining and analytics to identify fraudulent, erroneous, or abusive claims, supports resolution with improved workflows,

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