Accountability in Action award winner personifies hard work and positive attitude

Justin DeMoss was pretty surprised to find out he was Discovery Health Partners’ most recent Accountability in Action award winner. When the award was announced at the company’s quarterly meeting, Justin was away on vacation.

“All of a sudden my phone is blowing up with messages that said, ‘Hey, you won’ and ‘Congratulations,’” he says.

“It was a big surprise for me because I didn’t think I’d even be a finalist. It was certainly much appreciated. It means a great deal to me.”

The Accountability in Action award recognizes Discovery employees who go above and beyond to contribute to the company’s key results by living the “what else can I do?” attitude.

“With the accountability concept, everyone feels willing to say when they need help, and as a team we hold each other accountable,” says Justin. “The idea of accountability in action gives us more of a personal responsibility to raise our hand if we need help and we work together to fix it.”

“That’s the message I continue to demonstrate to our team as well as others I’ve worked with,” according to Justin. “If we see someone who is struggling, we hold out a hand to help them. We’re accountable to that person to help them get the job done.”

Discovery’s culture of accountability

Justin started with Discovery in 2019 and leapt at the chance to work with IT and the Development team on the company’s payment integrity platform, ReThink.

“ReThink is our internal auditing engine,” he explains. “It essentially sets the data up in a view so our auditors can look at it efficiently with some case logic to whittle down members’ claims in order to deliver the best potential cases for us to pursue. It makes auditing more efficient.”

Now a Supervisor of Content Development and Data Management, Justin manages a group of senior auditors. In addition to his supervisory role, he works cross-functionally with the IT, Implementations, and COB Operations teams, along with other key stakeholders, to develop ReThink client implementations and enhancements.

“I’m kind of the COB ‘boots on the ground’ kind of person, you could say. I work closely with my senior director Ron Jones, Coordination of Benefits Senior Manager Diana Rivas, and Coordination of Benefits Supervisor Nadia Zaragoza to get things done. I work with the senior auditors to develop content, perform testing within queries and categories, and verify auditing concepts are solid so we can move work into production.”

“Last quarter, I had the opportunity to work with Irena Trajkovski, the senior technical project manager for ReThink, who nominated me for the accountability award,” Justin shares. “She recognized the dedication and hard work I had put in to get a major platform update done.”

Justin shares credits with his coworkers

Justin gives credit to his fellow Discovery employees, including Ron Jones and Nadia Zaragoza.

“Ron trusted me and gave me the opportunity to run with ideas that I believed could add value for our clients. He has been a great mentor to me since I’ve been with Discovery. And Nadia was my supervisor before I was promoted. I’m not sure anyone works harder than Nadia, and there aren’t enough words to say how much I appreciate her.”

Team exemplifies grit

“When I started the ReThink project back in December of 2019, I felt comfortable knowing I could reach out to someone and say, ‘I’m having a little trouble with this query, could you help me out?’ They were always willing to teach me—not just to do it for me, but to show me why. That’s the Discovery culture. People here are always willing to show you and teach you something new,” Justin says.


“Everyone is very willing to pitch in, stick their neck out to try to help, and then collaborate to find the best solution.”


“Our team exemplifies grit. You could definitely call us gritty. I haven’t met one person here who wasn’t willing to get their hands dirty. Whether with something they had no knowledge of and they wanted to learn, or something they’re very knowledgeable about and wanted to teach others.”

“My team is great—and is one of the best things about working at Discovery,” says Justin. “I absolutely love all the people that I work with. They make this job so much better. We had morning standups every single day at 9:30 to talk about what’s up for the day with the ReThink project. Those 9:30 morning meetings with Irena and the whole IT team were always awesome because of the people.”

Finding the best solution together

“We’re all from different backgrounds,” explains Justin, “We’re willing to sit back and listen to input and then bounce it off each other. All our senior auditors each have about a decade of experience. We’ve been doing this a long, long, long time—we know the things to look out for. What was awesome was even when I first started, this team saw value in what I brought to the table and listened to my input.”

“Being able to work on the ReThink platform and helping develop that from a user standpoint is a big accomplishment,” Justin says. “I get to open up ReThink every day and see my fingerprints on it. I get to see the things I helped develop and the impact I’ve made to drive this team forward for the foreseeable future.”

Working productively remotely

“As a healthcare technology company, Discovery manages working remotely productively and flexibly,” says Justin.

“Though I miss the ability to turn around in my cubicles and ask someone to look at something, or pass someone in the hall and have that quick 2-minute conversation, or even talk about that game last night—working remotely has allowed me to see the personal side of my coworkers who are working from home.”

Justin lives near Louisville, Kentucky, with two dogs and a cat and admits that the coronavirus lockdowns have cut into two of his favorite hobbies—golfing and travelling.

“I’m sure people laugh at me now during videoconference meetings because I got a new puppy in October, and she’s running my life. Breezy, a Great Dane pup, loves to curl up in my lap, and every once in a while when we’re having a meeting, she decides to show her face. Everybody knows her already.”

“I’ll definitely be using my extra paid day off from this award for a golf outing,” he says, laughing.

Justin DeMoss is a Supervisor of Content Development and Data Management at Discovery Health Partners. Justin started with Discovery in 2019 and brings over a decade of experience in the insurance industry to his role.


Discovery has built a culture of accountability throughout the company and created a quarterly award to recognize employees that have a stake in the company and go above and beyond by living the “what else can I do?” attitude.

Congratulations to Q3 2020 Accountability in Action award runners-up!

Sami is able to not only recover more money than before, but he is endlessly coming up with diverse, creative and efficient ways to recover more funds for our clients.
Christine Garcia, Accountability in Action award runner-up
“Edgar consistently goes above and beyond to provide valuable support for resolving system and technology-related issues. His persistence and tenacity enable him to resolve things swiftly.”

If you’d like to learn more about the steps to accountability and building this kind of culture at your organization, we recommend the book The Oz Principle.

Discovery Health PartnersAccountability in Action award winner personifies hard work and positive attitude
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Data Mining FAQs

We’ve compiled answers to some of the common questions we get from health plans as they look to build or expand data mining capabilities for their organizations.

Is there a certain dollar threshold for claims you’ll review?

Discovery works closely with clients to mutually agree on an overpayment threshold. The majority of our clients set the threshold at $50-$100.

Do you rely only on algorithms or only on manual review for data mining?

Discovery relies on both algorithms and our experienced Data Mining team to identify overpayments. The algorithms drive the sample of claims from which the auditors will filter and sort to identify/validate the overpayments that have the highest scored accuracy, dollar value, time sensitivity, etc. Every overpayment we identify is 100% validated in the client system. Overpayments are never sent out the door without “human touch,” which minimizes the amount of oversight required by the client.

How long before an identified data mining concept can be moved in house?

This varies depending upon the root cause of the overpayment, but we partner with our client’s in-house team every step of the way. For example:

  • A contract load error can typically be resolved in a shorter period of time
  • Decimal point error on surgical case rate ($50,000.00 vs. $5,000.00)
  • A claims processing error that is contrary to policy design and intent may require a longer period of time for resolution
  • Claims processing allowing ungrouped surgical procedures to pay at total claim percentage of billed charges vs. line item percentage of billed charges

Is there a standard integration process for Data Mining services?

Discovery does not use a standard integration process; we customize the process based on each client’s specific requirements. Our flexible integration approach minimizes our client’s time and resources—we configure our workflows and file transfers based on the client’s custom rules and codes, utilize the client’s existing specifications and data feeds, and accepts the client’s data in its existing format.

What’s the best way to approach data mining without harming our provider relationships?

Through our work with dozens of health plans, Discovery has found that the most effective way to introduce data mining is through a phased approach. This approach allows us to help health plans balance overpayment identification while maintaining positive provider relationships. Discovery uses a three-phased approach.

Phase 1: Global concepts

These are “black and white” overpayments with little to no room for contract or regulatory interpretation. Global concepts are applicable to all lines of business. The most common examples include:

  • Duplicate payments
  • Excessive charges
  • Excessive units

While all adjudication systems deploy edits to prevent these global concept overpayments from occurring, they are not always simple to catch and prevent. As an example, duplicate payment errors are more than just “the same claim paid twice.” Duplicates can occur across a subscriber and dependent, two different provider NPIs under the same tax ID, or multiple interim claims with overlapping dates of service. Discovery deploys multiple queries to identify all possible scenarios at both the header-claim level and the detail-line level.

Phase 2: Contract & policy concepts

These concepts are based off billing guidelines and require an analysis of contract terms to develop and deploy. Contract and policy concepts include:

  • Medicare pricing for all claim types (inpatient, outpatient, rehab, etc.), including any retroactive updates from CMS
  • Medicare readmissions and transfers
  • Modifier reductions, including assistant surgeon/non-physician practitioner reviews and practitioner/surgery validation
  • Multiple procedure reduction, including surgery and imaging services

Phase 3: Contract deep-dive

The last phase introduces custom concepts based on a client’s specific provider and plan contractual language. Below are some example targets:

  • Correct reimbursement for combinations of observation, emergency room, and surgery
  • Stop-loss provisions
  • Implant and high-cost drug thresholds
  • Carve-out validation

Not all our clients move through all these phases. Some decide to stay in Phase 1 and may approach Discovery if they have a specific need. Others will give Discovery full access to contracts and policies. There is no right or wrong approach—we are flexible and tailor our Data Mining services to the exact needs of each client.

Discovery Health PartnersData Mining FAQs
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Discovery makes Crain’s Chicago Business Fast 50 list for fourth time

Discovery Health Partners has been named to the Crain’s Chicago Business Fast 50 list for 2020. This is the fourth time in Discovery’s history that it has made Crain’s list of Chicago’s best and most innovative companies that are experiencing revenue growth at impressive rates.

Combined, the businesses on Crain’s 2020 list grew revenue from $3.9 billion in 2014 to $12.6 billion in 2019, which translates to 225.5 percent growth. Since 2007, the Crain’s Fast 50 feature has spotlighted local companies that have achieved impressive revenue gains over a five-year period in business, real estate, technology, health care, marketing, retail, logistics and more. As such, the project annually offers a reliable snapshot of the region’s growth sectors. To be considered for participation, companies had to have generated a minimum of $15 million in revenue in 2019, be headquartered in the Chicago area (the counties of Cook, DuPage, Kane, Lake, McHenry and Will as well as Lake in Indiana), and have been in business a minimum of five years.

See the full list and rankings here.

Discovery Health PartnersDiscovery makes Crain’s Chicago Business Fast 50 list for fourth time
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Discovery Health Partners named to Crain’s Chicago Business Fast 50

ITASCA, IL (October 12, 2020) – Discovery Health Partners announced today that it has been named to the Crain’s Chicago Business Fast 50 list of fastest growing companies in Chicago. To achieve its spot on the list, Discovery had to demonstrate an aggressive five-year revenue increase marked by year-over-year growth.

“Discovery is proud to make the Crain’s Fast 50 list this year and to have our team’s success and hard work recognized,” said Discovery Health Partners CEO Jason Brown. “Sustaining the type of growth that earned our spot on this list is a testament to the powerful combination of people and technology solutions that Discovery has assembled.”

This is the fourth time in the company’s history that Discovery has made the Fast 50 list. This distinction adds to other recent significant growth news coming out of Discovery, including its recent acquisition of Consova and its seventh consecutive placement on the Inc. 5000 list of fastest growing companies in America.

Full results and rankings of the Crain’s Fast 50 list can be found here.

About Discovery Health Partners

Discovery Health Partners’ mission is to deliver unique, actionable analytic insights and technology-powered solutions to help healthcare payers improve payment integrity, increase revenue optimization, and maximize efficiencies. Serving more than 80 health plans across the U.S., including nine of the 10 largest U.S. health plans, Discovery has been recognized consistently for its growth and innovation—earning a spot on the Inc. 5000 list seven years in a row, the Crain’s Fast 50 four times, and a prestigious FutureEdge 50 Award from IDG for innovations in machine learning. For more information on Discovery Health Partners, go to www.DiscoveryHealthPartners.com.

Read more about the powerful payment integrity solutions that helped Discovery earn its spot on the Crain’s Chicago Fast 50 list.

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Discovery Health PartnersDiscovery Health Partners named to Crain’s Chicago Business Fast 50
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Jeffrey Fasy joins Discovery Health Partners as Chief Financial Officer

ITASCA, IL (September 29, 2020) — Discovery Health Partners has tapped Jeffrey Fasy as its new Chief Financial Officer. Fasy brings decades of strategic financial management and financial analytics capabilities, along with robust experience in healthcare technology and data-centric organizations.

“We are pleased to add Jeff to our executive team,“ said Discovery CEO Jason Brown. “His skill set combines growth management expertise and deep appreciation for delivering continued client value. Jeff will be strong leader and help us navigate toward our overall key results.”

“I’m thrilled to have landed at Discovery,” commented Fasy. “We have great people and a very strong foundation to build on. I’m looking forward to helping the team sharpen their focus on client value, which I believe is the way we all win—our clients, employees, investors, and Discovery.”

Fasy most recently served as SVP, Financial Planning and Analysis, for nThrive, a revenue cycle management company for health care providers, and as Vice President of Revenue Assurance and Global Financial Planning and Analysis for Cotiviti, a solutions and analytics company for healthcare companies. Prior to those, Fasy held a variety of financial leadership roles at companies such as Equifax, SNF Holding Company, Kemira Chemicals, UCB, Inc., and Procter & Gamble.

Fasy’s appointment follows other recent significant growth news coming out of Discovery, including its recent acquisition of Consova and its seventh consecutive placement on the Inc. 5000 list of fastest growing companies in America.

About Discovery Health Partners

Discovery Health Partners’ mission is to deliver unique, actionable analytic insights and technology-powered solutions to help healthcare payers improve payment integrity, increase revenue optimization, and maximize efficiencies. Serving more than 80 health plans across the U.S., including nine of the 10 largest U.S. health plans, Discovery has been recognized consistently for its growth and innovation—earning a spot on the Inc. 5000 list seven years in a row, the Crain’s Fast 50 four times, and a prestigious FutureEdge 50 Award from IDG for innovations in machine learning. For more information on Discovery Health Partners, go to www.DiscoveryHealthPartners.com.

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Discovery Health PartnersJeffrey Fasy joins Discovery Health Partners as Chief Financial Officer
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Award-winning Irena Trajkovski’s superpower is her team

Irena Trajkovski, Senior Technical Project Manager at Discovery, is a winner of this quarter’s Accountability in Action award. For Irena and many in IT, sitting in front of a computer screen all day can make it difficult to see the big picture and understand how their work helps the company achieve its goals. That all changed when Discovery implemented its accountability program. Irena said, “It makes my work more meaningful. It’s motivating to know that what I do as a project manager contributes to Discovery’s larger goals.”

Beginning in 2019, Discovery built a culture of accountability that helps employees think and act in new ways to achieve key company results. The program is founded on four best practices of accountability:

  • Identifying gaps in execution
  • Personally owning responsibilities and aligning them to the company’s key results
  • Creatively and collaboratively working on solutions
  • Actively executing on solutions while building an environment of trust

Irena embodies these traits in her work. In March 2020, Irena led a special project to convert COB client data from an existing platform to the company’s new ReThink tool. The new data analytics platform gives claims auditors the tools they need to work more efficiently and more easily identify recovery opportunities for clients. Crucial to the success of the program was migrating data to the new platform and ensuring its accuracy without interrupting auditors’ work.

The accountability program played a key role in the success of the project.


“The accountability program changed the perspective of project management,” said Irena. “It empowers everyone, regardless of their role, to know that they can make an impact. If they see something, they can take the initiative to do something.”


The program helps employees identify whether their behavior is “above the line” or “below the line,” Irena explained. “We can call out ‘below the line’ behavior, encouraging others and examining what we can do personally to stop complaining about circumstances and, instead, go the extra mile. That has been very impactful for me as a project manager and for the whole team.”

One example of this happened when Irena and her team lacked quality assurance resources to test their work. Rather than letting it stop them, the team asked themselves what they could do about it. They identified someone on the team who had a similar skill set and took the initiative to fill that role.

When asked about the impact of the program, Irena said, “It has really provided a breath of fresh air for our company and inspires and empowers people to feel like they can make a difference. It connects our work to the company’s mission and goals.”

Irena credits her team for her success with the accountability program. “My superpower is my team,” she said. “I work with a team of talented individuals. When they are doing their best, it motivates me to do my best.”

When she’s not busy at work, Irena is busy at home with two toddlers, ages two and three. She enjoys going on nature walks with her husband and kids, doing daily yoga or Pilates, and trying new recipes in the kitchen.


If you’d like to learn more about the steps to accountability and building this kind of culture at your organization, we recommend the book The Oz Principle.

Discovery Health PartnersAward-winning Irena Trajkovski’s superpower is her team
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Discovery Health Partners named a “Top 100 Finalist” in the Chicago Innovation Awards program

ITASCA, IL (September 16, 2020) – Discovery Health Partners has achieved a spot as a “Top 100 Finalist” in the Chicago Innovation Awards program. Discovery is nominated in the “Innovations in Healthcare” category and it is the company’s second time making this exclusive list. In its 19th year, the Chicago Innovation Awards has a history of recognizing the most innovative products and services in the Chicago region.

Discovery is being recognized for its case open logic machine learning initiative as part of its claims ranking process within its Subrogation practice. Already acknowledged as an innovation leader in healthcare by IDG-CIO earlier this year in their FutureEdge 50 program, Discovery’s case open logic initiative leverages its decade of case outcomes data to fuel a subrogation model that eliminates hours of manual work, results in more accurate case identification, and reduces member friction.

As a Chicago Innovation Awards Top 100 finalist, Discovery will participate virtually in the Chicago Innovation Awards final event on October 19, 2020, where winners in each category will be announced.

About Discovery Health Partners

Discovery Health Partners’ mission is to deliver unique, actionable analytic insights and technology-powered solutions to help healthcare payers improve payment integrity, increase revenue optimization, and maximize efficiencies. Serving more than 80 health plans across the U.S., including nine of the 10 largest U.S. health plans, Discovery has been recognized consistently for its growth and innovation—earning a spot on the Inc. 5000 list seven years in a row, the Crain’s Fast 50 four times, and a prestigious FutureEdge 50 Award from IDG for innovations in machine learning. For more information on Discovery Health Partners, go to www.DiscoveryHealthPartners.com.

Discovery Health PartnersDiscovery Health Partners named a “Top 100 Finalist” in the Chicago Innovation Awards program
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Award winner Christine Garcia knows accountability isn’t a solo act

One way that Discovery delivers on its core values of reliable results, trusted quality, and profound client value is by building a culture of accountability. Discovery has invested in a comprehensive accountability model based on the concept that when people take personal ownership of the company’s goals and accept responsibility for their own performance, they work at a higher level to ensure their own success and the company’s overall success. Each quarter, Discovery’s Accountability in Action award recognizes Discovery employees who demonstrate they have a stake in the company and who go above and beyond to contribute to the company’s key results by living the “what else can I do?” attitude.

This quarter’s Accountability in Action award recipient is Christine Garcia, Senior Director of Shared Services and Quality Management at Discovery. Christine received the award for implementing improvements that positively impact all four of Discovery’s Key Results for 2020. In her seven years with Discovery—starting as a legal assistant and working her way up through a variety of positions and departments—Christine has gained extensive knowledge of Discovery’s day-to-day processes. She has seen first-hand how each individual and team can impact clients. When Christine took over as head of Shared Services, she drew on that experience and immediately set to work to identify opportunities for improvements, including process efficiencies and incoming mail handling processes that better meet client expectations. She also invested time in employee communication and development, providing continuous support and promoting talented supervisors and team leads, whom she credits for helping her earn this award.


“I’m very honored to receive the Accountability in Action award, but I know it wasn’t a solo effort. The collaboration and teamwork of many talented people in the company helped get me here,” she says.


Christine also credits the company’s Accountability in Action program itself as a big part of her success. She notes that since the accountability program began, she has seen a significant shift away from emphasizing individuals’ roles and contributions and, instead, toward a more collaborative mindset. By tying accountability to key enterprise metrics, the program has made individuals more aware of their everyday impact.

“Accountability is everyone’s responsibility, and the program has actually made my job easier because everyone is in lockstep now and looking at everything they do with an eye on accountability. Discovery has done a great job of supporting this program and continuing to build a culture that challenges everyone to consider if what they are doing is truly contributing to our goals. This focus helps to evaluate improvements and implement ones that create a more positive impact,” Christine explains.

For Christine, having oversight of the call center, settlement and recovery processes, user acceptance testing for program enhancements, and quality auditing programs has helped her gain a more a holistic view of how individuals and team actions impact the entire organization. It has also created more transparency and enabled Christine to position herself as a go-to resource for many other departments. “The program encourages others to reach outside their given roles and share their skills and ideas when they see an opportunity,” she says.

Christine is currently a student in the Loyola School of Law Weekend Executive program, and she plans to use her Accountability in Action cash award and extra day off with pay toward her education. True to her views on personal accountability, says she will use her law degree to continue fighting healthcare waste, fraud, and abuse at Discovery. When she’s not studying, she enjoys creative outlets including music and art and spending time with her two cats and one golden retriever.


If you’d like to learn more about the steps to accountability and building this kind of culture at your organization, we recommend the book The Oz Principle.

Discovery Health PartnersAward winner Christine Garcia knows accountability isn’t a solo act
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Discovery Health Partners enhances capabilities with acquisition of Consova’s payment integrity business

ITASCA, IL (August 27, 2020) – Discovery Health Partners, an industry leader dedicated to helping healthcare payers solve payment and revenue integrity challenges to improve financial outcomes, today announced they have acquired Consova’s payment integrity business.

This acquisition greatly expands Discovery’s growing Data Mining expertise and capabilities. Discovery assumes ownership of Consova’s payment integrity assets, including:

  • A team of seasoned medical claims analysts with a proven track record of accuracy in overpayment findings and recoveries
  • A robust set of unique, proprietary algorithms and process automation that combs through data in medical claims to select those that are most likely billed, coded, or submitted in error
  • A marquis list of top-10 health plan clients

With this latest acquisition, Discovery advances its position as a leading payment integrity solution provider. This acquisition represents an additional step in Discovery’s strategy of leveraging technology and advanced analytics to offer a full suite of payment integrity solutions for health plans.

“We are excited to welcome the Consova team and clients to the Discovery family. The combination of Discovery and Consova deepens our data mining and analytics expertise while expanding our growing client footprint,” commented Jason E. Brown, CEO of Discovery Health Partners. “We are thrilled to now be able to offer our vastly expanded expertise to clients, enabling them to recover significantly more claims overpayments.”

“Our payment integrity solutions have found a great new home with Discovery,” added Vino Ramayah, Consova’s CEO and Chairman. “Given Discovery’s demonstrated ability to grow their solution portfolio and customer base, we know that the data mining analytics and staff Consova has built will flourish and allow Discovery to rapidly grow their footprint in the health plan marketplace.”

Discovery has maintained an exceptional growth record over the last several years; the company recently received the prestigious Inc. 5000 Fastest Growing Companies award for the seventh year in a row. Only a very small fraction of the companies that apply for the list makes the list more than once, and only 1.26 percent of those companies have made the list seven times. Read the news here.

Comprehensive solutions for a growing industry problem

The estimated cost of waste in the US health care system ranges from $760 billion to $935 billion, accounting for approximately 25% of total health care spending, and the projected potential savings from interventions that reduce waste, excluding savings from administrative complexity, ranged from $191 billion to $286 billion, representing a potential 25% reduction in the total cost of waste. Implementation of effective measures to eliminate waste represents an opportunity reduce the continued increases in US health care expenditures.1 Healthcare claims processing is as profoundly complex as ever and is only made more difficult by numerous EMR vendors and compliance issues.

Through proven data mining practices, Discovery tackles this industry issue by identifying and recovering overpayments caused by inaccurate contract pricing, improper billing and coding, and misapplied reimbursement methodologies. The combination of expert auditing and coding staff, advanced analytics, and a best-in-class ReThink payment integrity platform enables Discovery to rein in wasteful spending and recover lost healthcare dollars for health plans.

About Consova

Founded by seasoned healthcare executives and powered by the Global Healthcare Technology powerhouse Cereus Health Group, Consova knows what it takes to contain healthcare costs. The company’s goal is to improve clients’ financial performance without diminishing the level of benefits that is offered to employees and members. For more information, go to www.consova.com.

About Discovery Health Partners

Discovery Health Partners’ mission is to deliver unique, actionable analytic insights and technology-powered solutions to help healthcare payers improve payment integrity, increase revenue optimization, and maximize efficiencies. Serving more than 80 health plans across the U.S., including many of the 10 largest U.S. health plans, Discovery has been recognized consistently for its growth—earning a spot on the Inc. 5000 list seven years in a row and the Crain’s Fast 50 three times. For more information on Discovery Health Partners, go to www.DiscoveryHealthPartners.com.

1Waste in the US Health Care System: Estimated Costs and Potential for Savings | JAMA Network  (October 2019)

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Discovery Health PartnersDiscovery Health Partners enhances capabilities with acquisition of Consova’s payment integrity business
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End-Stage Renal Disease (ESRD) FAQs

We recently talked about the need for Medicare Advantage plans to ensure that premium dollars coming in from the Centers for Medicare and Medicaid Services (CMS) are accurate. As with Medicare Secondary Payer, Medicare Advantage plans are losing out on premium dollars from members with End-Stage Renal Disease (ESRD).

Members with End-Stage Renal Disease account for a disproportionate amount of medical expenses. Experience shows that health plans are underpaid an average of $50,000 in CMS premiums for each misidentified or inappropriately documented ESRD member. Correcting inaccuracies and ensuring accurate submissions to CMS help plans restore millions in underpaid premium dollars. Here are answers to a few frequently asked questions about End-Stage Renal Disease validation:

What is End-Stage Renal Disease (ESRD)?

End-Stage Renal Disease, also known as ESRD, is a condition in which there is permanent and almost complete loss of kidney function. Some of these patients are treated by dialysis or kidney transplant. If members are flagged appropriately with the Centers for Medicare and Medicaid Services (CMS), the Medicare Advantage plan will receive the appropriate premium amount to pay for their care.

The challenge with ESRD members is that it is up to dialysis providers to submit appropriate documentation to CMS for members with ESRD. The plan has no control over this. Dialysis clinics can be difficult to work with due to high turnover and a lack of motivation to ensure accuracy.

What is the financial impact of ESRD to Medicare Advantage plans?

Medicare Advantage plans pay the full cost of ESRD claims, regardless of the amount of premium dollars received from CMS. For the sake of comparison, the average Medicare Advantage premium is $815. The average ESRD premium is $7,100. Multiply the difference over multiple members and multiple months, and the financial impact becomes significant.

What are common reasons that ESRD status is missed?

There are three areas where ESRD status is missed and where recovery opportunities exist. First, there may be members with ESRD diagnoses that the plan never knew about. Second, the member may have been flagged with ESRD at one point in time, but the flag was turned off and never turned back on. This may happen in a scenario in which the member went to hospice for a period of time. Lastly, the ESRD dates might not line up. CMS may not have paid the ESRD premium for the first few months of dialysis treatment.

What does ESRD validation entail?

When looking to ensure accurate premiums for ESRD members, the plan needs to first verify where it might recoup premiums due to missing ESRD flags. Once those members have been identified, the plan will want to ensure the complete and accurate submission of required documentation to CMS. Plans can recoup ESRD premiums for the previous 84 months.

Some Medicare Advantage plans find that they lack the resources to focus on ESRD validation or lack continuity due to multiple points of ownership throughout the organization. And the process of identifying members, gathering and correcting documentation, and working with dialysis clinics can be time-consuming and overwhelming. In these cases, the plan is wise to work with an ESRD validation vendor.

What do I need to consider when partnering with an ESRD validation vendor?

There are several factors to consider when evaluating ESRD validation partners. Most important is making sure the vendor has experience in the process and has developed proven best practices with measurable results.

Analytics plays a key role. The ideal partner will have developed advanced analytics and strong proprietary algorithms to find eligible members. Also important are established relationships with dialysis centers across the country and best practices developed with CMS over time.

In addition, the partner will manage the entire process from start to finish, requiring minimal to no involvement from the plan. The vendor will use proprietary analytics to identify members with the highest propensity of inaccurate ESRD statuses, perform subject matter expert review, work with dialysis clinics to correct data inaccuracies, submit accurate reports to CMS, and monitor the submission and acceptance process.

Lastly, the vendor will offer complete transparency by tracking, reconciling, and reporting on the progress of ESRD efforts and resulting financial outcomes.

 

Contact us today for more information about how Discovery Health Partners can improve your ESRD validation and premium restoration programs.

Discovery Health PartnersEnd-Stage Renal Disease (ESRD) FAQs
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