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, and promotes ongoing payment efficiency. Areas of payment integrity include coordination of benefits, subrogation, claims audit, and contractual compliance, among others.
It may seem cliché to start a blog post with a definition, but with the number of challenges and lack of clarity around payment integrity, we thought it was a definition worth examining. In fact, we’ll be spending a lot of time thinking about payment integrity in 2015.
This year, the Discovery Health Partners and Ajilitee teams will be focusing on payment integrity including the current state of payment integrity and the scope of the challenges that surround it. We’ll also examine its importance to health plans and the steps health plans can take to refine and improve their payment integrity processes and results. Each quarter we will present a payment integrity topic and spend a couple of months providing insight and information around that topic. There are several questions we’ll be examining over the course of 2015. Topics will include:
- Why is payment integrity critical to success? Examining the costs and risks of not addressing payment integrity holistically and proactively.
- What challenges do health plans face when attempting to address gaps in payment integrity? Including the organizational and information structures that can create barriers to improvement.
- How can technology solve payment integrity challenges? Addressing the critical points in the payment integrity process where technology can have positive impacts.
- How can health plans measure success? Evaluating the tools and practices necessary to track and improve results.
We’ll be examining these questions in a variety of ways and creating new content throughout the year to help shed new light on a challenging topic. Some of the highlights you can look forward to are:
- Customer testimonials and results information. We’ll be talking with our clients about the payment integrity challenges they have faced; the technology and tools they used to solve them; and the specific financial improvements they achieved. Our clients include regional and national plans from across the country including two of the largest plans in the country, prominent Blues plans, and plans with diverse types of coverage and membership. We’ll be sharing these stories in upcoming infographics, videos, and case studies.
- Expert insights. We’ll be working with our team of industry experts to develop and share new approaches, ideas, and best practices. In conjunction with our clients and analyst partners, we’ll be creating new webinars, podcasts, and videos to help support health plans’ payment integrity initiatives.
- New solutions and technology. Throughout the year, we’ll be delivering new solutions that will complement a comprehensive approach to payment integrity. We will also demonstrate the strength of our current suite of solutions that deliver sophisticated data mining and integration, factor scoring, and better analytics and reporting. Our solutions are developed with industry expertise, client input, and hands-on, in-house experience. We’ll showcase all of these solutions at industry conferences, invitation-only demonstrations, and client events.
We’re looking forward to our 2015 payment integrity journey, and we invite you to join us as we challenge traditional ideas, form new opinions, and deliver better results. We’ll be back in February with our next update, but until then, feel free to check out our suite of payment integrity solutions:
Discovery Health Partners offers the Discovery Payment Integrity SuiteTM of software and solutions to help health plans and other healthcare organizations improve recoveries, avoid costs, and optimize revenue. We offer a unique combination of deep healthcare expertise and powerful technology solutions to help our clients drive improved payment integrity and generate measurable results.
Ajilitee provides healthcare information and analytics consulting specializing in payment integrity, business intelligence, information management, and agile analytics. We bring a rare blend of business acumen, industry expertise, technical proficiency, and consulting excellence to our client engagements. Our award-winning information experts create agile IT environments using cloud-based technologies and architectures for faster time-to-benefit with less cost and risk.
Discovery Health Partners and Ajilitee are divisions of LaunchPoint, which was recently named the 100th fastest-growing company on the 2014 Inc. 500 list and #14 in Healthcare. LaunchPoint operates businesses that provide cloud-based analytic solutions, software, and services for healthcare organizations.