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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