Accountability in Action award winner personifies hard work and positive attitude

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

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

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

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

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

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

Discovery’s culture of accountability

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

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

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

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

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

Justin shares credits with his coworkers

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

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

Team exemplifies grit

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


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


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

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

Finding the best solution together

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

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

Working productively remotely

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

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

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

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

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

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


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

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

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

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

Discovery Health PartnersAccountability in Action award winner personifies hard work and positive attitude
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WANTED: new answer to growing COB problem

As many as 15% of your health plan members have other insurance coverage, creating a multi-million dollar impact on your health plan’s time, resources, and, ultimately, bottom line. In instances of overlapping coverage, health plans shoulder the burden of accurate claim payments. The arduous process of identifying other insurance, validating coverage status, and recovering incorrectly paid claims all generate substantial administrative costs and greatly affect provider and member relationships.

There are several trends that contribute to the issue of incorrectly coordinated claims. First are continual changes in membership. Take, for example, the nation’s aging population. Increasing numbers of baby boomers are reaching age 65 and becoming eligible for Medicare. At the same time, the percentage of retirement-age Americans who continue to work has doubled since 1985, surpassing the 20% mark in February 2019. Many of these older workers are covered by both their employers’ plans and by Medicare. In addition, health plans’ current claims processing environments entail highly manual, error-prone methods for verifying eligibility and insurance information. As many as a third of claims are paid incorrectly each year, contributing to approximately $1 trillion in annual waste.

Halloween at Discovery

These trends create a need for a new, modern approach to coordination of benefits (COB). In today’s competitive marketplace, the old tried and true approach to coordination of benefits—sending lots of member surveys (that cause member abrasion) and doing routine data mining (which produces lots of false positives)—isn’t enough anymore.

Bringing COB into the 21st century, Discovery blends the right people, processes, and technology to allow our team and our clients to work smarter rather than harder, effectively integrates data sources, looks at member eligibility holistically, and determines the most successful indicators or combination of indicators of other coverage.

A.I., meet H.I.

Our “modern” approach to COB does not mean that we’ve completely automated the process. To the contrary, Discovery believes that machines (A.I.) are only part of the coordination of benefits equation. It is the human intelligence (H.I.) component of our coordination of benefits solution that makes it very effective—and really special. A.I., meet H.I.

Sure, Discovery has built custom technology that is really awesome and supports intelligent coordination of benefits workflow and accurate findings. But it is the human factor that is Discovery’s secret sauce—the irreplaceable factor that brings things like critical thinking and an awareness of member sensitivity to the equation. It is this nexus of cutting-edge technology and amazing people that modernizes our approach to COB.

The human component of our Coordination of Benefits solution is comprised of subject matter experts with extensive experience working directly for both payers and providers. This combination creates a unique perspective in not only how to identify COB value for health plans, but also how to implement and operationalize a process that will be the least intrusive for the provider community. Everyone, including our COB leadership, has actually been in the payment integrity space on the front lines (as analysts) at one time or another. We know what it takes to bring maximum value.

Intelligent platform + data sources + matching capabilities

We pair our COB human intelligence with an intelligent, custom-built platform that supports the entire COB lifecycle. Going way beyond routine data matching, our process includes intelligent matching, workflow management, and machine learning algorithms.

Discovery uses many data sources in our algorithms. There are thousands of data sources available—some of which present a high return, while others provide minimal value. Based on our experience, Discovery focuses on the more intelligent sources that historically have a high yield. Our program consists of both traditional data and nontraditional data sources, and we’re continually evaluating new sources with high potential.

Discovery uses several matching processes to ensure the most comprehensive and accurate results possible. We supplement the demographic matching points (e.g., member name, member date of birth) by identifying and updating missing or incorrect information that is preventing a correct match. For example, our process seeks to verify inconsistent address information (“123 South West Main Street” vs. “One Two Three SW Main St.”), name normalization, and partial matches when most but not all key elements match. Additionally, we review case explosion opportunities such as when a member lives in the same household as dependent-aged children.

A modern, intelligent blend for coordination of benefits success

Discovery blends our rock-star COB human intelligence with advanced technology capabilities to deliver great results for our clients. It’s a modern COB solution that we’re proud to bring to health plans across the country now and into the future.

Ron JonesWANTED: new answer to growing COB problem
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Award-winning Irena Trajkovski’s superpower is her team

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

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

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

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

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


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


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

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

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

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

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


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

Discovery Health PartnersAward-winning Irena Trajkovski’s superpower is her team
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Your COB questions answered

As we meet with health plans of all shapes and sizes across the country, we’re frequently asked for advice regarding the Coordination of Benefits process, vendor selection, and orchestration with internal COB teams. Here, we share several of the common questions and our responses. 

Why consider Discovery Health Partners’ COB solution?

Your health plan’s success is based on the speed and accuracy of claims payments. Up to 15 percent of all members have other health insurance in any given year, costing plans millions in higher payments and administrative costs.

The Discovery COB solution is designed to go beyond other COB vendors by identifying more members with additional coverage—leading to less provider and member abrasion, additional claims recoveries, and avoided future expenses. Leveraging the power of technologies like Artificial Intelligence (AI) and predictive modeling, Discovery effectively integrates both traditional and non-traditional data sources to identify and determine the most successful indicators or combination of indicators of other coverage. We then use this information to automatically update analytic models to reflect that learning.

Does our organization need to change our existing COB processes?

No, your organization does not need to change its existing COB processes. Our COB solution is designed to work in concert with your existing internal and/or external vendor processes by harnessing the power of data mining and analytics to identify additional opportunities for recovery. To minimize duplication of efforts, our highly experienced staff works in partnership with your in-house COB, Operations, and IT teams. This enables your organization to retain current staff and gain additional savings. Our solution provides health plans with a “safety net” that delivers considerable incremental recovery opportunities with minimal disruption to operations.

How is Discovery’s COB solution different from internal operations or external vendors?

We built Discovery on both our staff’s deep subject matter expertise and the experiences learned while delivering successful payment integrity programs. Unlike traditional vendors that heavily rely on direct outreach, Discovery’s COB solution combines advanced technologies and extensive healthcare expertise to look at member eligibility more holistically, resulting in an increased number of high-value opportunities often missed by traditional means.

What does Discovery’s COB process look like?

Discovery takes a very flexible approach to its COB solution to accommodate different clients’ needs. Some of the options we offer with our COB solution include: mirroring a client’s internal COB team approach, acting as a turnkey vendor for COB efforts, focusing our COB efforts on all lines or business, and performing COB for only certain LOBs and/or claim types.

Does line of business matter?

No, line of business—whether commercial, Medicare, or Medicaid—does not matter. Discovery’s extensive knowledge of the various rules and regulations for each line of business allows us to perform COB services for all your covered lives. Discovery’s propriety algorithms and mining efforts are customized to deliver the most value possible across all your lines of business.

What should our organization look for when evaluating COB vendors?

The payment integrity market includes a wide range of COB vendors who offer to maximize recoveries and prevent future costs. When evaluating vendors, here are some things to think about:

Data: Where is the potential vendor getting its data and is the data relevant to your plan?

Expertise: What type of clients does the COB vendor work with today? Are they specialized in one line of business or do they work across multiple? Does the vendor have folks with plan-side experience?

Satisfaction: Does the vendor have a track record of delivering value to its clients?

Flexibility: Is the vendor flexible enough to wrap around your current team?

Technology: Is the vendor using technology like AI and machine learning to look at eligibility more holistically?

Research and development: Is the vendor relying on standardized practices that “worked before”? Or do they have a team of seasoned research analysts dedicated to looking for new rules, regulations, data sources, and data points to deliver additional value?

Full-service capabilities: Does the vendor offer solutions spanning all phases of the claims lifecycle (e.g., prospective, retrospective, hospice, etc.)?

Security: Is the vendor HIPAA and HITRUST compliant? What security standards and access policies are in place?

Partnership: Is the vendor willing to learn about your organization, what’s important you, and how to support your COB process and goals? Is this a joint collaboration and journey? Where does your plan line up with the vendor’s other clients? Will you be a priority for them?

 

Discovery is more than just another vendor—we are your partner, looking out for you every step of the way with proactive insight and information. Is this what you’re getting today? Learn more about our Coordination of Benefits solution.

Discovery Health PartnersYour COB questions answered
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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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eBook: Restoring millions for your Medicare Advantage plan

eBook: Restoring millions for your Medicare Advantage plan

Correctly paid Medicare Advantage premiums are a critical source of revenue for many health plans

Unlock the hidden value in your data to identify root causes of errors and collect the full value of premiums owed to your plan.

Download our eBook and find out how a Premium Restoration strategy can help you:

  • Identify members with premium restoration potential
  • Improve process efficiencies
  • Monitor the financial impact
  • Maintain ongoing premium restoration activities

Discovery Health PartnerseBook: Restoring millions for your Medicare Advantage plan
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Infographic: Fixing payment integrity at the source

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.

Infographic: Fixing payment integrity at the source

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

Discovery Health PartnersInfographic: Fixing payment integrity at the source
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Fixing payment integrity at the source

“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.
Jeff MartinFixing payment integrity at the source
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Jason Brown on the road ahead for payment integrity

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.

 

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

Jason BrownJason Brown on the road ahead for payment integrity
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Three ways to tackle the high cost of waste

New research published by the Journal of the American Medical Association (JAMA) estimates that 25% of U.S. healthcare spending, or $760 billion to $935 billion, is spent annually on waste1. According to the study, the greatest source of waste is administrative complexity, which accounts for $265.6 billion in annual waste.

Part of this administrative burden stems from a complex claims adjudication process impacted by legacy or outdated technology, a lack of clear contract or policy information, and no universal way for sharing information (e.g., member’s name, diagnosis code, etc.). These administrative challenges results in data and eligibility errors that are made throughout the claims continuum, resulting in millions of dollars in improper payments.

Life of a claim: Errors along the way

Payment Integrity continuum DiscoveryDespite the best efforts to address waste, administrative complexity in the healthcare system continues. Recent research from JAMA shows that measures to eliminate waste would result in a 25% improvement, but there’s more work to be done. Finding the root causes of errors is the most effective way to ultimately remove waste—and the high cost of it—from health plans’ payment integrity operations.

Here are three approaches to combatting the high cost of waste in your payment integrity strategy.

1. Reduce manual processes

Manual processes are often at the heart of human error. Manual processes are tedious, error-prone, and inefficient, contributing to the high cost of waste in healthcare. When your entire claims adjudication or payment integrity process contains manual tasks, the likelihood of error is high. Reducing or eliminating manual effort in your payment integrity processes will go a long way toward reducing waste.

2. Use technology to your advantage

Technology plays a key role in taking out waste from the payment integrity process. But outdated or legacy technology can create just as much waste as you might find with manual processes. With the right technology in place, you can modernize your payment integrity processes and reduce the amount of time and effort associated with correcting complex claims.

By the same token, emerging technologies like artificial intelligence and machine learning solve traditional payment integrity problems in new and innovative ways. These technologies offer analytics and predictive insights that can optimize your claims payment processes and drive data-driven decisions.

3. Look to a partner for advanced capabilities

A partner can supplement your in-house operations and offer the expertise you need to reduce waste. The right partner will bring robust capabilities that round out your core operations—capabilities like data mining techniques that prevent incorrect and unnecessary payments; industry experts who are up on the ever-changing and complex healthcare landscape; and processes that identify opportunities to correct, recover, and prevent improper payments at all points in the claims’ lifecycle.

The high cost of waste can threaten the viability of organizations throughout the healthcare ecosystem. With a holistic, connected payment integrity strategy built around these three tenets, your organization can improve operational efficiencies and achieve financial integrity by preventing improper payments—all while eliminating waste and generating meaningful results.

To learn how Discovery Health Partners can help you advance into the future of payment integrity, contact us today.

1“Waste in the US Health Care System: Estimate Costs and Potential for Savings,” JAMA, October 7, 2019.
Discovery Health PartnersThree ways to tackle the high cost of waste
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