Clinical Audits Archives - Discovery Health Partners

DRG validation strategies for success

August 13, 2020 Clarissa McCormick, RHIT, CCS Blog Post

Research into medical billing errors shows that as many as 80% of medical bills contain errors. In 2017, CMS paid $390 billion in claims, $36 billion of which were paid in error. There are several common coding and billing error types, with incorrect DRG coding being one of them. As health plans conduct clinical audits, DRG validation plays an important role in ensuring the accuracy and validity of payments.

DRG coding errors can be caused by clerical oversight or fraudulent practices. These errors can have a significant impact on payments and the health plan’s ability to maintain payment integrity. By auditing DRG coding, health plans can work to ensure that claims comply with all guidelines and that any uncovered overpayments are recovered accordingly.

The following strategies help health plans ensure their DRG validation audits are successful.

1. Analyze trends in data

When performing a DRG validation audit, data analytics plays a key role. Sophisticated data analytics technologies include predictive analytics, rules-based algorithms, and machine learning techniques. These technologies can examine hundreds of variables from multiple data sources and bring coding errors to light.

With these tools, payers can uncover trends and patterns in incorrect coding. Rather than sifting through hundreds of claims without direction, those trends and patterns highlight the most frequent coding errors and enable auditors to review only the claims that are most likely overpaid.

2. Trust coders’ professional knowledge

While data analytics can highlight trends in incorrect coding, DRG validation audits require the knowledge of a seasoned coding professional. A trained and knowledgeable staff—coupled with data analytics—can review and analyze historical claims data, medical records, and databases to quickly pinpoint errors.

To ensure proper learning, professional coders are credentialed through organizations like AHIMA that offer education, training, and certification. AHIMA helps coders gain a fundamental to advanced understanding of clinical diagnosis coding, as well as detailed insights into all types of DRG methodologies including MS-DRG, AP-DRG, APR-DRG, and Tricare DRG.

3. Get clinical validation

The expertise of a coder reaches a limit when physician documentation and clinical indicators appear to be imprecise or incomplete. Only a trained clinician—a nurse or physician—can call clinical decisions into question and get them corrected.

With clinical oversight, the health plan can be sure to conduct medically sound audits that reduce provider abrasion and ensure medically defensible recoveries. Physicians can help providers understand the medical rationale behind DRG coding inaccuracies and show providers where they may have gone wrong in their coding and documentation practices.

The combination of advanced data analytics, the knowledge and expertise of an experienced coder, and clinical oversight helps health plans achieve greater success with their DRG validation audits. Together, these strategies help health plans recover overpayments associated with coding inaccuracies—and potentially correct the practices that caused the errors in the first place.

Learn how Discovery Health Partners can help you enhance your DRG validation audits.

The impact of telehealth on clinical audits during COVID-19

August 5, 2020 Lynn Walter, MBA, RN, COC, CCFA Blog Post

Nowhere is COVID-19 felt more acutely than in healthcare. Hospitals are overloaded, clinicians are overworked, and ICU beds are scarce. The pandemic has also had an effect on the ways in which we seek non-emergent care. Telehealth has become a welcome relief for patients who need to seek care but want to stay in the safety of their homes. It also helps providers remotely screen and monitor COVID-19 patients without putting themselves at risk.

4,347% growth

in telehealth claims

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$250 billion

stated telehealth market potential

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7-fold growth

in telehealth projected by 2025

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In response to the growing need for telehealth, the Department of Health and Human Services issued a waiver on March 6, 2020, allowing all Medicare beneficiaries in all areas of the country to receive telehealth services from home. Previously, telehealth was only allowed in rural areas from healthcare sites. The waiver relaxes several other regulatory guidelines including those surrounding HIPAA, copays, deductibles, and more.

While telehealth has become a lifeline during the pandemic, the potential for improper coding and documentation—and fraud, waste, and abuse—is high. Until reimbursement for telehealth is better understood, health plans are wise to include telehealth claims in their clinical audit programs.

New telehealth regulations

As they manage telehealth claims, health plans need to first fully understand the new payment requirements. There are three types of telehealth services that fall under the telehealth expansion waiver:

Medicare telehealth visits are visits with a provider via telecommunication systems that offer audio and video
Virtual check-ins are brief, patient-initiated check-ins with providers via telephone or other device to determine whether an office visit or other service is needed
E-visits cover communications between a patient and provider through an online patient portal

The waiver also includes stipulations as to whether the patient must be an established patient. A range of providers including doctors, nurse practitioners, clinical psychologists, and licensed clinical social workers can offer telehealth services. In its fact sheet, CMS provides greater detail, as well as HCPCS and CPT codes for telehealth services.

Telehealth payment risks

Relaxing telehealth regulatory guidelines has led to growing concern about a potentially heightened risk of improper payments. Concern has arisen around a few factors:

CMS has approved 135 additional temporary billing codes for telehealth services, and new information and guidelines are changing by the minute, causing confusion and raising the risk of error
Penalties for some HIPAA violations may be waived to encourage telehealth, though this raises concern for patient privacy and safety
States and the federal government have loosened state licensing restrictions, allowing providers to work across state lines, widening the potential for liability and malpractice repercussions
States like California have their own telehealth regulations, which are stricter than the federal government’s. These state regulations must take precedence

Telehealth in clinical audits

As telehealth continues to skyrocket and with relaxed guidelines, health plans need to begin including telehealth claims in their clinical audit programs. Claims need to be reviewed for legitimacy to spot instances of fraud. Plans need to validate that services are coded and billed correctly and verify that appropriate documentation is included in all claims.

Telehealth has been making great inroads in helping to combat the COVID-19 crisis, but until it is better understood, health plans are wise to approach this uncharted territory with a dose of caution.

Learn more about Discovery’s Clinical Audit solution.

Three benefits of physician oversight in clinical audits

July 30, 2020 Moira Dolan, M.D. Blog Post

As I discussed in my earlier blog post, clinical audits play a critical role in ensuring payment integrity for health plans. They help to identify where payment errors are likely and help to correct those errors.

Previously, we talked about the need to care for providers during clinical audits, reduce abrasion, and protect the payer/provider relationship. In today’s blog post, we take the discussion a step further, identifying how physician oversight plays a role in conducting medically sound audits that reduce provider abrasion and ensure defensible recoveries.

Let’s discuss three topics in more detail:

1. Reducing provider abrasion

When conducting clinical audits, health plans must consider the experience from the provider’s perspective. While there’s little disagreement in the medical community that clinical audits are necessary, they can be tedious and expensive.

There are a few techniques I’ve used to help deliver a positive experience during clinical audits, making them less intrusive and more cost-effective for both parties. Education and transparency can have a significant impact on enhancing the provider experience. Clearly communicating expectations, requests, deadlines, and the plan’s findings go a long way toward improving the payer-provider relationship.

By being involved in these audits, I have come to realize that physician oversight helps to ensure a positive provider experience. When providers know that audits are medically sound and have been reviewed by a physician, they more readily accept the outcomes of the audit.

2. Providing the clinical perspective

When payment integrity is the goal, financial decisions cannot be the primary concern for both payer and provider. With physicians involved in the process, it’s understood that finances are not the motivating factor. By involving physicians, plans have the opportunity to communicate to providers that it’s not all about money and that there is clinical consideration given to audits.

In addition, physicians can help providers understand the medical rationale behind identified payment inaccuracies. We can help communicate compliance rules and show providers where they may have gone wrong in their coding and documentation practices. Ultimately, this helps providers learn from the audit and are more compelled to change their behavior.

3: Ensuring medically defensible recoveries

Whenever a clinical audit leads to the recovery of overpaid funds, the health plan must ensure that all clinical audit outcomes are defensible. Physician oversight helps ensure that audit decisions are made with clinical objectivity.

This is particularly true with medical necessity discussions. With high-dollar claim reviews and DRG validations, physicians collaborate with coders in developing review algorithms. In responses to appeals, physicians can review the audit decision and provide the clinical justification for the outcome.

In the end, physician oversight in clinical audits helps health plans ensure they are effective and reduce any abrasion that might be experienced by the provider. The physician can engage in peer-to-peer discussion with the provider and help them understand audit decisions from a mutually agreeable clinical perspective.

Learn how Discovery Health Partners can help you enhance the medical validity of clinical audits.

Moira Dolan, M.D., is Medical Director for Discovery Health Partners. She is a graduate of the University of Illinois School of Medicine and has been a practicing physician for over 30 years. Dr. Dolan maintains a private medical practice in Austin, Texas.

Trends that are re-shaping payment integrity strategies

July 16, 2020 Diane Akrami Blog Post

Evolving payment models and new technologies are supporting health plans’ efforts to implement more proactive, data-driven payment integrity solutions. Diane Akrami, Senior Director, Audit Operations, discusses what’s in store for the future of payment integrity and how the company is helping clients make the transition from retrospective to prospective programs.

During the last decade, a number of emerging trends have impacted health plans’ ability to reduce their exposure and increase payment accuracy. Value-based contracting, for example, has left many payers struggling to figure out how to transition to the performance-based payment methodologies that center on cost efficiency, quality, and delivery standards. The changes around CMS’ reimbursement models for home health and skilled nursing can pose some challenges as provider and payers adapt to those changes and create new PI audit opportunities. Payment integrity programs can provide needed support in adapting to claims processing changes like these.

At the same time, providers themselves are evolving and making changes to their billing processes based on these new models. In order to mitigate potential payment errors, health plans are moving from a retrospective process of identification and recovery to a more cost-effective prospective approach. Through clinical audits focused on the provider type, place of service, and their reimbursement models, plans can verify that services billed were performed, ensure proper payments, and avoid the costs of recovery. Payment integrity has a role to play here. Focused payment integrity programs that take a holistic approach to claims auditing enable health plans to shift from cost recovery to prevention and cost avoidance, thereby increasing claim payment accuracy.

Helping transform payment integrity approaches

As industry needs change, Discovery has been bolstering our payment integrity capabilities with experienced talent, technology platforms, and analytical tools. Our highly-experienced Clinical Audits team builds and deliver solutions for urgent care, home health, skilled nursing facilities, high-cost drugs, and other standard and client-specific audits, Our client-centric approach to payment integrity will allow us to continue expanding these types of services to address health plans’ needs as they arise—specialty audits for provider telehealth claims, for example—to support our clients’ cost avoidance and recovery operations.

Using data to evolve payment integrity approach

The healthcare industry is accelerating its adoption of cutting-edge technologies like artificial intelligence and machine learning to add efficiency and cut costs across operations, including in the payment integrity space. Discovery leverages analytics, artificial intelligence, and machine learning to audit millions of claims every month and find the “needle in the haystack” claims that yield the highest savings for health plans. We are also using analytics to identify patterns in client data that are specific to that provider. We can use that information to educate clients on how to address specific trends to improve their billing processes. We can also help them identify opportunities to change behaviors, so they are able to pivot to a proactive payment process.

Health plans are looking for a true partner who can help them support and enhance their payment integrity efforts so they can better control costs associated with incorrect billing and overpaid claims and improve administrative and medical loss ratios. With years of experience supporting both payment integrity and managed care, Discovery’s connected payment integrity approach—combined with our dedication to partnership, responsiveness, and relationships—delivers results that go far beyond financial value.

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

Caring for providers during clinical audits

July 9, 2020 Moira Dolan, M.D. Blog Post

For today’s health plans, clinical audits play a critical role in ensuring the financial health of the organization. They can help a plan control costs, comply with government regulations, and meet financial requirements. Fundamentally, clinical audits help to identify where payment errors are likely. There are many flavors of clinical audits—reviews for high-dollar claims, medical necessity, hospital bills, DRG validation, and skilled nursing care are among some of the most common.

Effect of clinical audits on providers

Whatever the flavor of the audit, it’s likely that clinical audits can create provider abrasion. As a medical director, I have experienced clinical audits and understand the reasons for the discontent. There’s little disagreement in the medical community that clinical audits are necessary, yet tedious and expensive.

In fact, nearly a third of providers report a negative experience with payer audits, according to a recent study by Frost & Sullivan. Providers report that their negative experience stems from factors including a high volume of medical requests, the prevalence of technical denials, and the high administrative costs of audit compliance.

More than 92% of survey respondents tie provider abrasion to the volume of medical requests. And 50% of providers consider clinical validation audits and DRG coding to be very or extremely labor-intensive. This is a critical factor given that labor intensity has a direct impact on administrative costs.

Improving the payer-provider relationship during audits

The good news is that any dissatisfaction in the clinical audit process is not irreparable. I have learned that provider-friendly techniques can go a long way toward delivering a positive experience during clinical audits, making them less intrusive and more cost-effective for both parties. Recognizing that clinical audits have the potential to cause provider abrasion is the first step to reducing discontent. Beyond that, communication and education are key.

Clear and transparent communication throughout the clinical audit process can have a significant impact on enhancing the provider experience. By clearly communicating expectations, health plans can alleviate provider unease with the audit process and mitigate the adversarial impact and stress related to clinical audits.

Providers are more likely to be amenable to the audit when they clearly understand requests, deadlines, and the plan’s findings. When they know what to expect and understand that the communication lines are open, providers are more likely to have a positive experience.

Similarly, education is an important tool in reducing provider abrasion. Perhaps the most valuable element of clinical audit education is helping providers understand how to change their behavior to reduce the impact of audits. Health plans can educate providers on the need for preventative measures in situations related to high-risk targets. Education can also include helping providers understand how to implement a proactive approach to address recurring problems.

Ultimately, with frequent and transparent communication and education throughout the clinical audit process, health plans can help providers view the plan in a favorable light and experience the audit without undue stress. With a positive clinical audit experience, payers and providers can work together to reduce the potential for post-payment recovery today and in the years to come.

Learn how Discovery Health Partners can help you enhance the provider experience in clinical audits.

Merging AI and human intelligence for big recovery results

May 27, 2020 Dan Iantorno Blog Post

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!

Protecting payment integrity through client-centered support

April 21, 2020 Monica Frederick Blog Post

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!

Infographic: Fixing payment integrity at the source

March 19, 2020 Discovery Health Partners Infographic

It’s a known fact that improper payments abound in healthcare. Given the effect that eligibility data can have on claims payments, a connected payment integrity approach is essential. Often, challenges arise from multiple sources of data, conflicting or inaccurate data, data integration challenges, manual workflows, multiple reporting systems, and more.

When eligibility errors occur, they affect many payment integrity areas such as coordination of benefits (COB), subrogation, and Medicare secondary payer (MSP) validation. Failing to address these issues leads to incorrectly paid claims, improper reimbursements, or claims that shouldn’t be paid at all—costing your plan millions.

Find out the top three causes of eligibility errors and learn how a connected payment integrity approach can help.

Fixing payment integrity at the source

February 6, 2020 Jeff Martin Blog Post

“New year, new me.” Seems like we hear this at the beginning of every year and hold on to the promise of moving on from the past and setting new goals for the future. Likewise, healthcare organizations are kicking off 2020 by charting new paths to address old problems and expanding into new initiatives to stay ahead of the competition.

Priorities such as increasing member satisfaction, provider relationships, and regulatory compliance remain top of mind for many health plans, which makes it a good time to take a fresh look at your payment integrity strategies and resources. Now is the time to evaluate how well your plan is maximizing recovery opportunities, improving cost avoidance strategies, and exploring premium restoration possibilities. To do this, you need to start at the source of your payment integrity challenges: eligibility data.

The impact of eligibility errors

It’s a known fact that improper payments abound in healthcare, many of which stem from eligibility errors made as a result of multiple data sources, outdated technology, manual processes, and members with other insurance coverage. When eligibility errors occur, they affect many payment integrity areas such as coordination of benefits (COB), subrogation, and Medicare secondary payer (MSP) validation. Failing to address these issues leads to incorrectly paid claims, improper reimbursements, or claims that shouldn’t be paid at all—costing your plan millions.

According to Gartner, billions of dollars are spent every year in improper claims payments across commercial, Medicare, and Medicaid lines of business. Gartner research states, “Payer CIOs must get proactive and leapfrog current performance by focusing on prospective payment integrity capabilities.” With this in mind, what can you do to strengthen your payment integrity approach?¹

Identify inaccurate eligibility data

When taking a close look at eligibility data, your plan will want to determine which claims may have been paid incorrectly as a result of inaccuracies. We estimate that 20% of a plan’s membership will have other insurance, and of that 20%, the other insurance will be primary 17.5% of the time. For a 200,000-member plan, this represents nearly $5.4 million in incorrectly paid claims. When statistics like this are uncovered, the plan quickly realizes how important it is to keep its eligibility data in check.

Determine a cost-avoidance strategy

Avoiding improper payments is a core tenet of any payment integrity strategy. Accurate and trusted eligibility data plays a key role. We estimate that the same 200,000-member plan could save over $13.4 million by avoiding incorrect payments. With the right cost avoidance strategies founded on accurate eligibility data, the plan stands to see a significant impact to its bottom line.

Look beyond dollars and cents

When evaluating your payment integrity strategy, you will want to think beyond dollars and cents. Quality eligibility data will have a positive effect on administrative efficiency, member satisfaction, and provider relations.

By avoiding improper payments in the first place, you avoid the need to rebill, saving you and your staff valuable time and energy that might be channeled toward other payment integrity initiatives.

Member satisfaction is a key priority for any health plan. In fact, the member experience drives performance on CAHPS (Consumer Assessment of Healthcare Providers and Systems), which is a key driver of Star ratings. Eligibility data drives a diverse number of systems and processes including registration, enrollment, care provision, wellness, and customer care. All of these areas influence your members’ experiences with your plan.

Lastly, providers depend on prompt, accurate payment. When claims are denied as a result of recurrent eligibility issues, payer-provider relationships already burdened by administrative complexity are further strained. Ensuring accurate eligibility data and determinations not only improves efficiencies, it also helps to accelerate reimbursements, greatly improving relationships and alignment.

Consider a connected payment integrity approach

Given the effect that eligibility data can have on payments, you will want to consider a connected payment integrity approach and address any gaps in your technology. Often, challenges arise from multiple sources of data, conflicting or inaccurate data, data integration challenges, manual workflows, multiple reporting systems, and more. By creating a technology environment that can support connected payment integrity functions (e.g., claims recovery, subrogation, and COB), business managers and IT can come together in their thinking and create a single, trusted source of eligibility data.

Contact Discovery Health Partners today to find out how we can support your payment integrity initiatives in 2020 and beyond.

¹Gartner, “U.S. Healthcare Payer CIOs Must Adopt Prospective Payment Integrity to Thwart Improper Claims Payment and Fraud,” February 13, 2018.

Jason Brown on the road ahead for payment integrity

January 16, 2020 Jason Brown Blog Post

As the industry transitions from volume to value-based healthcare, health plans face increasing pressure to better manage costs and ensure payment integrity. We recently sat down with Jason Brown, CEO of Discovery Health Partners, to get his thoughts on recent trends and how they’re shaping the road ahead in 2020.

Healthcare continues to change and evolve. What do you see as some of the trends setting the stage for optimizing payment integrity?

Health plans face a number of challenges when it comes to ensuring the right care is provided to the right member for the right amount. Complex billing processes, changing regulations, outdated and disparate data systems, and overlapping coverage all contribute to improperly paid claims. Today, nearly a third of claims are paid incorrectly, leading to billions in administrative waste.

In 2020 and beyond, we anticipate health plans will continue to struggle with rising healthcare costs, numerous competing priorities, and a lack of resources. Furthermore, changing regulations and mandates will continue to add layers of administrative and clinical complexity to a system already bogged down in paperwork. While there is no clear path to cost containment, there are ways health plans can work toward transforming their payment integrity approaches. An example is leveraging advanced technologies to move from retrospective payment to prospective payment—by detecting improper claims before they are paid, health plans can keep costs in check, increase member satisfaction, and most importantly, cultivate healthy provider partnerships.

What are some of the ways Discovery is helping health plans address their payment integrity challenges?

This past year has been an exciting time of innovation and growth for Discovery. We have an expanded suite of payment integrity solutions—Coordination of Benefits, Subrogation, Data Mining, Clinical Audits (in areas such as diagnosis-related group (DRG) audits and itemized bill review audits) and Premium Restoration. Our integrated solutions are designed to work together. This connected approach helps optimize claims recoveries and avoid future expenses across the entire claim lifecycle while reducing provider and member abrasion.

What makes Discovery unique is that our solutions start with our clients’ own data and processes. We leverage the latest analytical tools and technology like machine learning to identify patterns that present opportunities for cost recovery and cost savings. By blending artificial intelligence with human expertise, we identify hidden errors and root causes that are often overlooked. We also provide the highest levels of support to our clients, acting as an extension of their teams, to free up their internal resources so they can focus on other business priorities.

Since its inception, Discovery has been proud to provide flexible solutions that help health plans solve their payment integrity challenges. Our newly formed Client Council provides a platform for clients to share industry insights and challenges with their peers and help drive product innovations with Discovery. Going forward, custom-tailored solutions like ours will be key to helping plans manage costs while maintaining the high levels of care that their members expect.

What’s on the horizon for Discovery in 2020?

During the past decade, we’ve demonstrated measurable success by helping our clients improve operational efficiencies, increase claims accuracy and payment, and recover dollars back to their health plans.

From 2020 forward, we will continue to evolve existing solutions and create new forward-thinking approaches to help plans prevent and recover inaccurate payments. By expanding our use of data analytics and data integration and accelerating our investments in research and technology like machine learning and predictive analytics, we will help health plans capitalize on information to coordinate claims correctly. Once individual plans reach the point where they are paying the appropriate amount for the healthcare that’s delivered, they can re-invest in clinical care for their members.

At the same time, we will position clients to transition toward a more proactive approach to cost management. Reimagining the payments process and applying insights further upstream will be key to enabling providers to take advantage of opportunities to proactively change wasteful behaviors.

And of course, we’ll continue to keep our finger on the pulse of the industry. By building partnerships with our clients, industry organizations, agencies and others to learn about best practices and stay on top of the latest trends, we can prepare clients for the challenges ahead.