Merging AI and human intelligence for big recovery results

Technology plays a key role in health plans’ transition to more proactive, data-driven payment integrity results. We sat down with Dan Iantorno, Chief Information Officer at Discovery Health Partners, whose team received the FutureEdge 50 award from IDG/CIO magazine for Discovery’s work with machine learning and AI. We discussed how technology is driving a transformation in payment integrity and what Discovery is doing to help clients access new technologies to improve revenue, avoid costs, and enhance their members’ experience. 

Data and analytics are transforming many industries, including healthcare. What are the biggest challenges health plans face when implementing these new technologies?  
We know that health care costs are skyrocketing, driven by administrative complexity, fraud, and abuse. It’s estimated that as much as $935 billion, or nearly 25% of total spending, is wasted in the US healthcare system every year. As a result, providers are under intense pressure to manage costs and ensure payment integrity, while at the same time continuing to provide quality care for their members.

Technologies that leverage artificial intelligence, machine learning, and analytics can enable plans to implement process efficiencies and dramatically increase recovery rates, while reducing member abrasion. But many health plans lack the internal tools and resources to identify and pursue recovery opportunities for high-cost, complex claims. Discovery is partnering with health payers to support data-driven payment integrity solutions and help them identify and pursue the highest-value cases to drive bottom-line results.

What are some of the ways Discovery is innovating to help clients transform their payment integrity approaches?
Since the company’s inception, Discovery has been at the leading edge of analytics-powered technology solutions to help clients address payment integrity challenges. Today, we are using machine learning and predictive analytics to tap into the potential of more than a decade of case outcome data to improve results, drive efficiency, and guide our customers to more proactive payment integrity strategies. Last year, we unveiled our Case Open Logic solution, an initiative that uses machine learning as part of our claims ranking process in our Subrogation practice. 

Rather than relying on human logic to prioritize the 2% of cases that result in 90% of recoveries, our solution uses machine learning to augment human intelligence by selecting the cases with the highest likelihood of success, doing in seconds what would previously have taken hours of manual work. These enhancements help validate subrogation claims faster and more accurately and identify cases that otherwise might be missed. The process also helps health plans reduce member friction because there’s no need to contact members unnecessarily on claims that are not of substance. This solution has delivered immediate results for our clients, and the technology shows great potential to enhance solutions across business lines. We’re very proud that our Case Open Logic solution was honored with IDG/CIO’s FutureEdge 50 award that recognizes cutting-edge applications of emerging technologies to advance business goals. 

What’s in store for the future of payment integrity and how will Discovery support health plans as they evolve their payment integrity strategies?   
Discovery’s data science team has a history of blazing new trails in the payment integrity industry. In 2020 and beyond, we will continue to innovate with solutions that drive results for our health plan clients and provide best-in-class models for the industry. For example, our investment in machine learning with our Case Open Logic solution has already helped us boost subrogation recoveries for our customers by 20%. Based on that overwhelming success, we intend to roll out similar machine learning capabilities to other lines of business such as Data Mining, Clinical Audits, and Coordination of Benefits (COB). The application of machine learning based on a decade of data enables Discovery to provide services that are immensely valuable to our health plan clients. Combining technology innovation with our team’s decades of experience in the health payer space is how we will continue to deliver game-changing profound client value.

Find out how Discovery Health Partners can help strengthen your payment integrity initiatives in 2020. Contact us today!

Dan IantornoMerging AI and human intelligence for big recovery results
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Food for thought—an ingredient for good health

Today’s blog post is the third in a special series of posts that celebrates the month of May as Global Employee Health and Fitness Month, the international observance of health and fitness in the workplace. Our series, titled “Mind, body, and stomach,” is the work of Jim Heffernan, senior accountant at Discovery and Employee Wellness Committee ambassador.

I do love me some food! I believe you could deep-fry just about anything and it would taste great. I know it’s not good for me, but it just tastes so good! Growing up in an Italian household probably didn’t help me learn how to make good food choices. When you are surrounded by breads and pastas and wonderful desserts, it’s not easy to pick healthier options to snack on.

The first wealth is health -Ralph Waldo Emerson

Over the years, I’ve come to realize how important it is to incorporate healthier foods into my diet. Healthier foods help maintain a healthy body weight, increase proper nutrition, and promote an overall healthy body. Try some of these easy tips to improve your diet today!

Increase fruits and vegetables

A diet rich in fruits and vegetables is known to lower blood pressure, reduce the risk of heart disease and stroke, decrease digestive problems, and even prevent some types of cancer. Fruits and vegetables provide essential nutrients that can improve the health of your body

Need some ideas on how to increase your intake? Add roasted veggies to your meal. Find seasonal vegetables, sprinkle with olive oil, and roast them up. Stack veggies on your sandwich. Most people already add lettuce and tomatoes, but consider slicing up a cucumber or shredding a carrot and adding it to your sandwich. Make it a lettuce wrap and swap out the bread altogether! Add fresh fruit to your cereal or oatmeal in the morning, or pair fruits with cheese and a good glass of wine for an evening treat. 

Good carbs to eat

Carbohydrates are one of the body’s primary sources of energy and are an essential part of a healthy diet. A healthy diet should include more complex carbohydrates than simple carbohydrates. Complex carbohydrates are high in fiber and starch and take longer for the body to digest. They contain more essential vitamins, minerals, and antioxidants. Examples include grains, beans, and oats. Simple carbohydrates contain natural sugars easily digested by the body to provide quick energy. Examples of good simple carbs include fruits, vegetables, milk and milk products. Some examples of bad simple carbs include refined foods like soda, white sugar, and pastries. These are the items that should be a very limited part of your diet.

When you are cooking, try to use brown rice instead of white. Brown rice is a whole grain and higher in fiber than white rice, which has been processed. Brown rice also helps lower cholesterol, promotes fullness, and can help prevent blood clots. Another good carb to incorporate are vegetables, as mentioned above. Try baking a sweet potato or adding a side of roasted vegetables. You can’t go wrong with a simple side salad either—vegetable combinations are endless.

Water, water, water

Did you know that water carries nutrients to the cells in your body and oxygen to the brain? It helps the body absorb vitamins and minerals essential to the function of your organs. Water also helps regulate the body’s temperature and maintain bodily functions. It can boost skin health and lubricate joints, promoting beauty and reducing pain. Water is also a main component of the digestive system, converting food into energy and excreting waste from the body. 

You might be thinking it’s boring to drink a simple glass of water. Well, it can be. But did you know there are many food options high in water content? Cucumbers, tomatoes, and spinach are over 93% water. Melon, apples, and oranges are over 85% water. Besides the water consumption, these fruits and vegetables are good sources of the daily nutrients our bodies need. I bet you could grab a few off this list of top hydrating foods and toss them together to make a delicious salad or fruit plate! 

Healthy snacks  

Another way to maintain a healthy diet is to add healthy snacks to your day. Healthy snacks can increase your energy level and help you lose weight. They can improve your concentration, increase memory, and enhance awareness. Be prepared—have an assortment of healthy options available to keep you on track. Examples of healthy snacks include an apple or carrot sticks. Grab a handful of cashews. Have a bowl of cottage cheese and add some berries. Looking for additional snack ideas? Check out SnackNation’s list of healthy and filling snacks.

In addition to these tips, keep in mind it’s not always what you eat, but how! You need to get to the root of your nutritional imbalances. It’s not always where you go for lunch, but how often you go and what you choose to eat. Are you eating food too close to bedtime on a regular basis? Are weekends becoming your cheat days and causing you to binge on unhealthy foods? Mindful eating can even be as simple as looking at how quickly or slowly you eat your meals. There are many factors to look at when trying to sustain a healthy diet. Just remember, baby steps—Rome wasn’t built in a day.

Find out more about Global Employee Health and Fitness Month here.

James HeffernanFood for thought—an ingredient for good health
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The body issue—because we all have one

Today’s blog post is the second in a special series of posts that celebrates the month of May as Global Employee Health and Fitness Month, the international observance of health and fitness in the workplace. Our series, titled “Mind, body, and stomach,” is the work of Jim Heffernan, senior accountant at Discovery and ambassador of our Employee Wellness Committee.

Not everyone loves the physical cards they were dealt. Believe me, I sure don’t! But there are so many things we can do to change that. First, it starts with your mental approach. You have to get in the right mindset to change the body.

Exercise can make you feel happier. It has been shown to improve mood and decrease feelings of depression and anxiety. It helps build stronger muscles and bones, helping to reduce injuries and prevent osteoporosis later in life. Exercise can increase your energy levels and reduce feelings of fatigue. It can reduce your risk of chronic disease and improve brain function. And, obviously, it can help with weight loss. According to the CDC, many people sit at a desk all day, making us much more sedentary and leading to weight gain and other medical problems.

excuses don't burn calories

Just because you might be working from home, don’t have access to a gym, or don’t have all the professional equipment doesn’t mean you can’t get a good workout. Sometimes you just have to be a bit creative. Here are some creative workout ideas that might inspire you.

Walking

Sounds very easy—and it is. Grab your favorite shoes and go for a walk. You might even want to invite a friend along so you can encourage each other. Walking can improve your mood and reduce anger and hostility. It will help you burn calories and is one of the best low-impact ways to change your body composition. Walking can boost your immunity and reduce your risk of disease.

Resistance training

Resistance training is a physical activity that is designed to improve your muscular fitness and endurance. Usually this training incorporates weights or tension bands into the workout. But let’s say you don’t have access to weights or bands—then what are your options? Try doing exercises that utilize your own body weight. Try push ups, sit ups, jumping jacks, squats. You can even do exercises while holding household items. One good exercise to strengthen your core is planking. Planking engages many muscles across the whole body to improve posture, increase muscle definition, and improve balance. There are always opportunities when at home to get a good workout. Check out this article for additional workout tips.

Yoga and Pilates

Yoga is a form of exercise that focuses on breath control, simple meditation, and body posturing for improved health and relaxation. Its purpose is to bring the body, mind, and environment into harmony. Some benefits of yoga include increased flexibility, muscle strength, and improved respiration. Check out this beginner-level yoga workout.

Pilates consists of low-impact flexibility and muscular strength and endurance movements. Its purpose is to increase muscle strength, particularly in the abdomen or core. Some benefits include a total-body workout, improved posture, and decreased pressure on your knees and joints. Check out this beginner-level Pilates workout.

Extra creative workout ideas

Do you like to dance? Even if you don’t, try putting on some fun music and dance like nobody’s watching. It’s a great way to get your heart rate up, burn calories, and improve muscle tone. Or try boxing/kickboxing. You can take a class or just set up a weighted bag in your house and throw some punches. It’s my favorite way to relieve stress! How about housework? I’m not a fan of cleaning the house, but adding some loud music can make it fun and help burn some extra calories. If these ideas don’t appeal to you, you can find all kinds of free workout videos online. Find one you like and try it!

Incorporating exercise into your daily routine does not have to be difficult or time-consuming. You don’t have to spends hours in a gym lifting huge weights to improve your overall appearance. You just have to find something you are interested in and stick to it. Make your workouts fun and change them up as needed. Set goals, encourage yourself, and achieve them. In time, you will see a difference, feel better, and—most importantly—improve your overall health.

Find out more about Global Employee Health and Fitness Month here.

James HeffernanThe body issue—because we all have one
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Find the funny—laughter’s healing power

Today’s blog post is the first in a special series that celebrates the month of May as Global Employee Health and Fitness Month, the international observance of health and fitness in the workplace. Our series, titled “Mind, body, and stomach,” is the work of Jim Heffernan, senior accountant at Discovery and Employee Wellness Committee ambassador.

 

An accountant by trade, I’ve been working on Discovery’s Finance team for over two years and have been in this profession for over 20. One thing I’ve found to be true—accounting and creativity are not a good mix on the job. It’s not a good idea to get “creative” with a company’s finances—it’ll usually land you on the front page of the Wall Street Journal for all the wrong reasons.

In order to express my creative side, several years ago I decided to sign up for an improv acting class to channel my creativity. I found this outlet to be more than just learning improv; it allowed me to be creative and confident with my comedy and found a whole new community to work with. In turn, I formed an improv comedy troupe and have enjoyed creating laughter ever since.

What I’ve learned first-hand over the years is that laughter is a very important part of health and wellness.

“A day without laughter is a day wasted.”

Charlie Chaplin

When was the last time you laughed so hard you cried? How did you feel after that bout of hysterical insanity? I bet it felt great. There are medical reasons for this feeling. It has been proven that laughter improves your heart, lungs, and muscles due to an increase in oxygen intake. Also, laughter can relieve stress and help you deal with difficult situations. When you laugh, the body releases endorphins, which are the body’s natural feel-good chemical. These endorphins lighten your mood and possibly help you live a longer life.1 Laughter is also linked to burning calories. And believe me, I’ll take a good laugh-until-you-cry moment over exercise any day!

We all need to increase our opportunities to laugh these days, especially while working from home due to COVID-19. With limited social interactions, finding the right way to express ourselves becomes more difficult. We need to find those outlets for laughter to continue to improve our well-being and keep ourselves interested and engaged. Here are a few ideas that can help bring some laughter into your otherwise ordinary day.

Fun with children

There was a whole television show based around kids saying the darnedest things! It’s very true. Sit down with your kids and tell funny stories and jokes. Pull out games or puzzles and play together. Suggest something crazy like an obstacle course through the house or dressing up in crazy outfits. You’ll be shocked how much you laugh and, in turn, your child will laugh with you. It’s important to take the time to have fun as a family.

Fun with pets

Laughter is an important part of human interactions. When you live alone with a pet, you tend to treat your pet as your companion, and he can provoke laughter in you. Think about it this way, if you talk to Fido, why wouldn’t you laugh with him, too? Get down on the floor and play tug-of-war or throw a ball. I bet you laugh. People tend to laugh when they see a dog fail at catching a ball or do something unexpected like jumping on the ball. This surely will bring a smile to your face.

Fun with co-workers and friends

Humor is a social activity. That’s why you laugh more watching a movie in a theater full of people rather than alone in your house. Reach out to your co-workers or friends. Schedule a meeting for lunch and share some of the funny things that have happened to you or your family—you may be surprised how happy this will make you. Nowadays, you can do almost anything virtually, from playing games to happy hours. You just have to find the right platform and enjoy the fun.

Fun everywhere

It’s important to find opportunities that work for you based on your individual style. There are many multimedia platforms, ranging from television shows and movies to online videos to visiting a comedy club. During this time, there are many comedy clubs that are offering online performances and classes you can take. Check your local neighborhood listings for these opportunities.

There are literally hundreds of possibilities for increasing laughter in your life. You need to find what’s funny to you. It can be as easy as finding some simple items like comic strips or funny photos—put them on your refrigerator, add funny quotes to your home office, watch your favorite funny movies, or listen to comical podcasts when you need a humor boost. I think it’s safe to say that we are all experiencing a certain degree of new stress these days. Find a way to laugh about your own situation and give yourself the permission to laugh at yourself! Feel the stress melt away. Make it a habit to find the funny every day and improve your overall well-being.

Find out more about Global Employee Health and Fitness Month here.

James HeffernanFind the funny—laughter’s healing power
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Six ways to help your remote workforce thrive

In the pre-coronavirus world, companies moving to a remote workforce could take months to develop and implement their plans. But the sudden onset of COVID-19 gave companies very little lead time to figure out how to set up and support employees to work from home. With no time for formal training, many organizations have been left wondering how they would help their employees stay motivated and productive in this new way of working. 

Discovery moved to a remote workforce model over a year ago and has gained a wealth of work-from-home expertise. Hoping to help other organizations thrive in this new remote world, we’re sharing some best practices based on what we learned.

1. Culture eats strategy for breakfast

Often attributed to management guru Peter Drucker, this adage reminds us that a company’s culture is often the glue that binds employees together and drives the desired behaviors throughout an organization. This holds true—and perhaps becomes even more important—when the “office” is virtual. Leveraging your organization’s culture will help employees feel more connected to each other and to the company. And it’ll create a virtuous cycle—the more you reinforce your culture, the stronger it’ll get. Is cross-functional team collaboration an important part of your culture? Use regular recurring meetings and communications—weekly emails from the CEO, monthly company meetings—to showcase how your teams are working collaboratively. 

2. Effective managers manage, wherever their employees are

Whether employees are in a physical office or working from home offices, effective managers are the ones who use the right combination of motivation, monitoring, and feedback to keep their teams productive and engaged. When faced with the need to manage their teams remotely, some managers may require more support than others. It can’t be overstated how important it is to invest in helping managers be effective—the ROI is huge. Tap into your highly-effective managers as resources to help build up other managers’ skills. Conduct regular meetings and trainings to reinforce best practices and develop management skills. When the pandemic hit, Discovery pivoted from monthly people manager meetings to weekly check-ins. This allows people managers to problem-solve the new COVID-19-related challenges their teams may be experiencing.

3. Make your expectations clear and water what you want to grow

Pandemic or no pandemic, a key to a company’s ability to reach its goals has always been setting clear expectations and ensuring that all employees understand those expectations. Clear expectations act as a connecting force throughout your team and organization, creating alignment so everyone is working together to make the right things happen. At Discovery, we’ve defined our expectations through our five Core Values—Trusted Quality, Reliable Results, Applied Innovation, Mindful Stewardship, and Profound Client Value. These values guide every single employee’s decisions and actions. 

Being clear with expectations must be coupled with holding ourselves and others accountable. Team and company leads need to proactively manage their processes in order to get the results they expect. Water what you want to grow—reinforce accountability, reward positive behaviors, celebrate employees who demonstrate their commitment to goals. When employees are remote, it’s critically important to do these things in a way that others can “see.” Discovery uses an online “Impressions” portal for giving and receiving kudos to employees who demonstrate behaviors consistent with our expectations. Everyone in the company can see who’s living our Core Values.

4. Trust…and verify

If you’ve clearly set expectations and are holding people accountable, then you’re well on your way to mastering this best practice. Being remote requires a good deal of trust that employees are managing their time effectively and concentrating on the right things. But you must also check in and check up. Make it a priority to connect with team members on a regular basis so they know you want to stay connected to what they’re working on. This also gives you an opportunity to ensure every team member has what they need to do their job effectively. Use a combination of instant messaging, video conferencing, email, phone, texts, or whatever works best for you and your team to be available and responsive when questions come up. Remember to also check in with employees frequently just to ask how it’s going.

5. Flexibility is free productivity…and free employee engagement

Flexibility is the secret sauce for helping remote employees stay productive. Nearly everyone’s daily life has been disrupted by social distancing, work furloughs, school closings, and other changes. Managers can help remote employees stay on task by working with them to establish schedules, processes, and timelines that balance individual needs with those of your team. Even a small accommodation like moving a meeting by 15 minutes can make a big difference. And remember, life at home still goes on even while employees are working. Learn to embrace those everyday interruptions!

6. Above all else, stay connected and communicate, communicate, communicate

Make sure your teams know what’s going on and have the information they need to do their jobs. People crave personal interaction, and working remotely can cause feelings of isolation and being cut off socially from coworkers. Carve out time during the day for your employees to connect with others. Take virtual coffee breaks or meet-up by video conference to brainstorm ideas, problem-solve, or just talk. You can even plan a virtual happy hour, virtual escape room, or other team events. It doesn’t have to be formal; be sure to lean on your employees for ideas. An unexpected benefit of working virtually is that co-workers are often more open and relaxed outside the office environment. Use this to your advantage and get to know each other on whole new level! 

COVID-19 has presented some unique challenges for organizations suddenly transforming to a remote workforce, and it may take some trial and error to find the right approaches to managing in this new environment. By focusing on the things that are important at all times—culture, effective management, clear expectations, flexibility, and communication—you and your remote workforce can indeed thrive!

Please stay safe and remember we’re all in this together! 

 

Share your work-from-home management tips with us on LinkedIn and Twitter.

Learn more about our response to COVID-19.

Philip GarrisonSix ways to help your remote workforce thrive
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Protecting payment integrity through client-centered support

Unexpected events like the COVID-19 pandemic make it increasingly difficult for health plans to manage costs and ensure payment integrity. We recently sat down with Monica Frederick, Vice President, Account Management for Discovery Health Partners, to discuss how Discovery’s people and account management approach contribute to our clients’ success.

You’re a newer member of the Discovery Account Management Team. Can you share your experience prior to Discovery?

Over the past 20 years, I’ve held numerous sales and business development positions to support healthcare organizations in bringing new patient care modalities to the market. My experience on the medical side gives me insight into how managed care organizations can strengthen their payment integrity efforts so they can better manage costs and continue to focus on member care.

What makes Discovery a successful team and what are we doing differently to support our clients’ success?

Discovery has built a solid reputation for providing value to health plans by helping to solve their payment integrity challenges. We owe our success to our exceptional people and culture of accountability. Every employee across the organization understands the importance of their role and how they contribute to our clients’ success. And I see the whole organization working tirelessly to anticipate customers’ needs and earn their trust.

Communication is a big part of our approach to account management at Discovery. We talk to clients frequently in person and virtually, and we also conduct client surveys to hear directly from our clients on how we’re doing and how we can continue to provide profound value to our clients’ organizations.

Through this hands-on approach, we’ve learned that we do many things right. Clients especially appreciate how we advise them to determine the best course of action for their operations and provide timely follow-up to address their concerns. This valuable feedback also helps us identify opportunities where we can improve our processes and solutions to better meet clients’ needs.

In addition, we have a Client Council that brings together individuals across our client base whose voices influence the future of our business. We host in-person and virtual meetings with our Client Council to deepen relationships and understand what clients need to be successful. These meetings not only provide clients with valuable networking opportunities, but also offers clients opportunities to share insights and best practices with other health plan leaders and drive future innovations.

What is Discovery’s approach to account management, and how do we drive value throughout the entire engagement with a client?

Our approach is flexible to meet each client’s unique needs, but it always starts with earning their trust, by getting to know them and understanding their business operations. We listen closely to their concerns and create a plan that addresses their challenges and aligns with their strategy and priorities.

When clients join Discovery, we put together an implementation team with the right skills and specific expertise to ensure a smooth, accurate, and efficient implementation. Our approach is flexible and can wrap around or come behind existing vendors and processes already in place. Discovery’s multi-disciplinary teams work collaboratively and our experts evaluate each client individually. There is no one-size-fits-all approach.

Once implementation is completed, an internal hand-off to the Account Management team occurs and all unique attributes and needs for each client are discussed in detail. A dedicated account manager takes the lead to provide guidance and manage day-to-day activities and communicate the status of ongoing projects every step of the way. We don’t just hand over reports; we take time to meet regularly with clients to review their information in a way that’s meaningful so we can make recommendations for improvements and achieve their desired results.

What are some of the ways Discovery helps health plans address unexpected payment integrity challenges like the COVID-19 pandemic?

COVID-19 is unlike any event the healthcare industry has seen in modern times, thus health plans are faced with challenges they could not have imagined just a few months ago. Not only do health plans need to ensure their members receive the care they need and support their providers, health plans must also keep up with individual states’ mandates regarding “non-essential” claims processes and review of COVID-19 related claims. At the same time, they are struggling with reallocating resources to support critical COVID-19 initiatives while managing the shift to a remote workforce.

Discovery is proactively reaching out to clients to make recommendations, based on their business, to help protect premium revenue, pick up productivity shortfalls as needed, and help them protect their workforce. We continue to work diligently on behalf of clients as an extension of their teams to ensure they get the right information to support the continuity of their operations.

Discovery went remote with payment integrity operations over a year ago, so we’re in a great position to help support our clients business during the pandemic. Discovery views challenges as an opportunity to learn from individual clients’ needs. As COVID-19 plays out, we will continue to partner with clients to make sure we are supporting them and their challenges are addressed in a timely manner.

 

Find out how Discovery Health Partners can help contribute to your payment integrity success in 2020. Contact us today!

Monica FrederickProtecting payment integrity through client-centered support
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Enhancing premium restoration in four steps

Today, more than 22 million seniors and people with disabilities choose a Medicare Advantage plan, and enrollment is projected to increase to an all-time high of 24.4 million this year1. Do you have insight into how much revenue your plan might be losing in underpaid premiums?

Ensuring accurate premium payments for your Medicare Advantage members requires the right people, processes, and technology to identify your potential for premium restoration. It all starts with data. By integrating data sources and viewing eligibility data holistically, you can easily identify members with the greatest propensity for inaccuracy: those requiring Medicare Secondary Payer (MSP) validation and those diagnosed with end-stage renal disease (ESRD).

Here are four steps you can take to capture underpaid premiums:

#1: Identify members with premium restoration potential

The undisputed first step in capturing underpaid premiums is identifying those members with premium restoration potential. Our experience shows that an average of 4% of Medicare Advantage members have open MSP records, and 50% of those records have premium restoration potential. By identifying members with MSP or ESRD, your plan can ensure those members are accounted for in MMRs and in payments from CMS.

#2: Improve process efficiencies

When analyzing open MSP and ESRD occurrences, your plan needs to identify and prioritize those that require investigation. By allocating scarce resources to the activities that will have the greatest impact on the bottom line, you can ensure that dollars and staff time are spent wisely and efficiently.

#3: Monitor the financial impact

As premium restoration becomes more complex and when resources are limited, sophisticated monitoring is needed to achieve the results your plan expects. With a proactive approach to monitoring premium restorations, you will want to forecast how many dollars will be added to the premium check, uncover whether you have received every month of restored premiums, and maintain an audit trail to validate the outcomes and steps taken to correct inaccuracies.

#4: Maintain ongoing premium restoration activities

Given the impact it can have on your bottom line, the premium restoration process must be maintained on an ongoing basis. By ensuring payment accuracy throughout the year, you can capitalize on significant revenue opportunities month after month, year after year.

Discovery’s data analytics combined with our deep understanding of CMS eligibility rules can help your plan unlock the hidden value in your data and collect the full value of premiums owed.

Discovery Health PartnersEnhancing premium restoration in four steps
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How COVID-19 trends are impacting payment integrity

At the close of 2019, healthcare predictions echoed the challenges of years past: complex billing processes, changing regulations, and rising healthcare costs. It was no surprise that health plans would continue to tackle these long-standing issues that contribute to improper claims payments in 2020. Little did we know, though, that payers would find themselves facing these challenges in very unexpected ways amid a global pandemic.

Health plans, bracing for the full impact of COVID-19, will need to find ways to navigate the uncharted course―a course that is no longer focused primarily on cost efficiency, quality, and delivery standards. Rather, a new course is taking shape that centers on safety, performance, and demand.

Promoting safety and well-being

In response to the COVID-19 pandemic, most states have issued shelter-in-place orders, requiring non-essential businesses and staff to work from home. Health plans are now faced with either remaining open as a critical operation or moving operations to newly established remote environments. For some plans, the transition from offices to mandatory work-from-home settings can present initial challenges (e.g., operational requirements, data security). As these challenges are addressed, payers are also working with their provider partners to increase access to care while protecting providers and the community. For example, the expansion of remote care and monitoring services help support social distancing and reduce the risk of exposure to COVID-19.

Facing financial performance impacts

The total number of COVID-19 cases continues to rise, prompting healthcare associations to recommend the suspension of elective surgeries and procedures to maintain sufficient capacity to treat patients and minimize risks of exposure. As those types of claims decrease, we anticipate a spike of high-dollar inpatient claims to treat individuals affected by COVID-19. In fact, a recent analysis by S&P Global estimates a severe COVID-19 pandemic could cost U.S. health plans more than $90 billion in medical claims alone1. While several major health plans have recently pledged to waive costs associated with COVID-19 treatment, we can expect these costs will cause health plans to experience significant financial stress.

To offset these great costs, we recommend health plans with large Medicare populations to look to other areas to positively impact revenue. For example, Premium Restoration (the recovery and protection of premium revenue) is one way to maximize financial performance in 2020 while not disrupting COVID-19 initiatives.

Increasing demands on healthcare organizations

It’s no surprise that as COVID-19 cases continue to grow, so are claims for testing and treatment and, more importantly, high-dollar inpatient stays. To this end, the Centers for Medicare & Medicaid Services (CMS) has issued new guidelines that lift restrictions and offer more flexible coverage options (e.g., tele-health). The American Medical Association (AMA) has also provided special coding advice to help healthcare professionals during the COVID-19 public health emergency. And in an effort to help ease the strain the pandemic is creating for healthcare providers, health plans are suspending reviews on COVID-19 related claims

With so many rapidly changing policies and requests, the regulatory burden is mounting for both health plans and providers alike. It will be more important than ever to make sure your plan has the correct member eligibility to avoid months of catch-up. Given these uncertain times, we highly recommend plans have a strong coordination of benefits (COB) program in place to ensure accurate and updated eligibility data while driving future cost avoidance.

Contact Discovery Health Partners today to find out how we can help you with your payment integrity efforts amid COVID-19.

Access the latest COVID-19 information from our COVID-19 response page.

Discovery Health PartnersHow COVID-19 trends are impacting payment integrity
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Restoring Medicare premium revenue during COVID-19

Medicare Advantage enrollment and the number of confirmed COVID-19 cases are on the rise. According to the Centers for Disease Control and Prevention (CDC), older adults and individuals who have health conditions like heart, lung, or kidney disease may be at a higher risk for complications.

Your Medicare Advantage plan relies on the Centers for Medicare and Medicaid (CMS) for information regarding other health insurance and certain health conditions. When this information contains errors, it affects your bottom line. For many Medicare Advantage plans, the losses can be more than they realize.

What can your Medicare Advantage plan do to maximize its financial performance during these challenging times?

You can begin to recover the premium dollars owed to your health plan by performing a retrospective review of eligibility data. Going back seven years, you can review your monthly membership report (MMR) files to look for indications that the health plan is owed additional premium reimbursement for certain members.

What are the top reasons for missed premium restoration cues?

There are several cues that a plan may miss when it comes to premium restoration:

  • Incomplete data aggregation from the plan’s IT department
  • Inaccurate member questionnaire data
  • Section 111 reporting inaccuracies by commercial plans
  • Inability to completely or accurately validate a member’s other insurance
  • ECRS Web rejections that should actually result in premium reimbursements

Finding the causes of these missed cues can be difficult. Would you even know if your IT department is sending you incomplete data? What if you cannot get another insurer to validate eligibility information for a member? If CMS denies a seemingly legitimate eligibility update, do you know how to overturn that?

How Discovery can help

Discovery Health Partners can strengthen your premium integrity efforts by taking a closer look at Medicare Secondary Payer (MSP) validation and members with end-stage renal disease (ESRD). A recent analysis by S&P Global Ratings states that COVID-19 will end up costing U.S. health insurers more than $90 billion in medical claims.1 More than ever, it is important for plans to chart a course for transformative action that not only protects their premium revenue but also protects their workforce. With more individuals working from home and being allocated to support critical COVID-19 initiatives, Discovery is ready to continue working diligently on behalf of our health plan clients to identify eligibility issues and premium reductions.

We have helped clients restore millions with our Medicare Secondary Payer Validation solution:

  • $2.1 million for a 20,000-member regional plan
  • $16 million for a 30,000-member Midwest plan
  • $5.7 million for a 200,000-member Blues plan

In addition, our ESRD Premium Restoration solution has helped clients restore:

  • $6.5 million for a 160,000-member Medicare Advantage plan across a two-year engagement
  • $4 million for a 230,000-member Medicare Advantage plan seven months after implementation
  • $3 million for a 100,000-member Medicare Advantage plan in 12 months

The amount of potential restoration opportunity is a function of four parameters:

  1. Successful validation of inaccurate records
  2. Number of months of restoration opportunity for each incorrect record
  3. Average monthly restoration amount
  4. CMS acceptance rate of corrections submitted

Contact Discovery Health Partners today to find out how we can help you with your premium restoration efforts as your health plan navigates the impact of COVID-19.

Access the latest COVID-19 information and guidelines from CMS.

Jeff MartinRestoring Medicare premium revenue during COVID-19
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Tips for staying connected amid COVID-19

As the COVID-19 outbreak continues, Discovery Health Partners employees are grateful to work remotely to help slow the spread of the disease. Discovery implemented remote and work-from-home capabilities over a year ago, which positions us extremely well to continue to support our clients’ business with minimal to no interruptions. In fact, we’ve already seen that our business model has helped us continue to be the partner our clients need in these very trying times.

But let’s be honest. In recent days, school closures and state ‘shelter in place’ orders across the country have created additional challenges for those who must now juggle both working and learning from home. Recognizing that many are grappling with these new routines, we are providing a list of best practices Discovery employees are using to stay connected.

1. Communicate, communicate, communicate

You can still stay close with coworkers while remaining socially distant. Now more than ever, it is vital to remain transparent regarding projects and work life so that everyone is on the same page and shares the same expectations. This could mean daily brief work huddles, a quick text, more meetings, or in some cases, less meetings. Teams should come together on what will work best for them and what is needed.

2. Establish a workspace and routine

Whether you are working from home alone or with a partner or family, setting up a designated workspace and schedule will help break up the day into more manageable parts. In the office, you might start your morning by grabbing a cup of coffee or tea and prioritizing emails. Replicating that same routine at home can bring normalcy into this ‘new normal.’ If you have children who are tackling distance learning and virtual assignments, make sure they are sticking to their typical school routines (e.g., lunch, recess) as well. And more importantly, set up times to answer any questions. This will help them not only remain engaged but also establish good habits in their later years.

3. Take breaks and stay active

When working from home, it’s easy to get trapped into a mindset that you need to appear available every minute of the day. But breaks are just as important at home as they are in the office or school. Make sure to carve out some time to step away, minimize eye strain, and regroup. You can use this time to take lunch, talk with your partner and/or children, or go on a quick walk or run. You’ll find stepping away can help bring priorities into greater clarity and help you stay more productive throughout the day. And regular exercise is good medicine for both mental and physical health.

It’s hard to predict what lies ahead as the COVID-19 pandemic runs its course. And adjusting to a new routine in a new world can seem overwhelming at times. In the face of these challenges, there are opportunities to invest in connections with each other and transform the way we work. Please take care of yourself, and remember, we will get through this together.

 

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Learn more about our response to COVID-19.

Discovery Health PartnersTips for staying connected amid COVID-19
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