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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Data Mining FAQs

We’ve compiled answers to some of the common questions we get from health plans as they look to build or expand data mining capabilities for their organizations.

Is there a certain dollar threshold for claims you’ll review?

Discovery works closely with clients to mutually agree on an overpayment threshold. The majority of our clients set the threshold at $50-$100.

Do you rely only on algorithms or only on manual review for data mining?

Discovery relies on both algorithms and our experienced Data Mining team to identify overpayments. The algorithms drive the sample of claims from which the auditors will filter and sort to identify/validate the overpayments that have the highest scored accuracy, dollar value, time sensitivity, etc. Every overpayment we identify is 100% validated in the client system. Overpayments are never sent out the door without “human touch,” which minimizes the amount of oversight required by the client.

How long before an identified data mining concept can be moved in house?

This varies depending upon the root cause of the overpayment, but we partner with our client’s in-house team every step of the way. For example:

  • A contract load error can typically be resolved in a shorter period of time
  • Decimal point error on surgical case rate ($50,000.00 vs. $5,000.00)
  • A claims processing error that is contrary to policy design and intent may require a longer period of time for resolution
  • Claims processing allowing ungrouped surgical procedures to pay at total claim percentage of billed charges vs. line item percentage of billed charges

Is there a standard integration process for Data Mining services?

Discovery does not use a standard integration process; we customize the process based on each client’s specific requirements. Our flexible integration approach minimizes our client’s time and resources—we configure our workflows and file transfers based on the client’s custom rules and codes, utilize the client’s existing specifications and data feeds, and accepts the client’s data in its existing format.

What’s the best way to approach data mining without harming our provider relationships?

Through our work with dozens of health plans, Discovery has found that the most effective way to introduce data mining is through a phased approach. This approach allows us to help health plans balance overpayment identification while maintaining positive provider relationships. Discovery uses a three-phased approach.

Phase 1: Global concepts

These are “black and white” overpayments with little to no room for contract or regulatory interpretation. Global concepts are applicable to all lines of business. The most common examples include:

  • Duplicate payments
  • Excessive charges
  • Excessive units

While all adjudication systems deploy edits to prevent these global concept overpayments from occurring, they are not always simple to catch and prevent. As an example, duplicate payment errors are more than just “the same claim paid twice.” Duplicates can occur across a subscriber and dependent, two different provider NPIs under the same tax ID, or multiple interim claims with overlapping dates of service. Discovery deploys multiple queries to identify all possible scenarios at both the header-claim level and the detail-line level.

Phase 2: Contract & policy concepts

These concepts are based off billing guidelines and require an analysis of contract terms to develop and deploy. Contract and policy concepts include:

  • Medicare pricing for all claim types (inpatient, outpatient, rehab, etc.), including any retroactive updates from CMS
  • Medicare readmissions and transfers
  • Modifier reductions, including assistant surgeon/non-physician practitioner reviews and practitioner/surgery validation
  • Multiple procedure reduction, including surgery and imaging services

Phase 3: Contract deep-dive

The last phase introduces custom concepts based on a client’s specific provider and plan contractual language. Below are some example targets:

  • Correct reimbursement for combinations of observation, emergency room, and surgery
  • Stop-loss provisions
  • Implant and high-cost drug thresholds
  • Carve-out validation

Not all our clients move through all these phases. Some decide to stay in Phase 1 and may approach Discovery if they have a specific need. Others will give Discovery full access to contracts and policies. There is no right or wrong approach—we are flexible and tailor our Data Mining services to the exact needs of each client.

Discovery Health PartnersData Mining FAQs
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Merging AI and human intelligence for big recovery results

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

Data and analytics are transforming many industries, including healthcare. What are the biggest challenges health plans face when implementing these new technologies? 

We know that health care costs are skyrocketing, driven by administrative complexity, fraud, and abuse. It’s estimated that as much as $935 billion, or nearly 25% of total spending, is wasted in the US healthcare system every year. As a result, providers are under intense pressure to manage costs and ensure payment integrity, while at the same time continuing to provide quality care for their members.

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

What are some of the ways Discovery is innovating to help clients transform their payment integrity approaches?

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

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

What’s in store for the future of payment integrity and how will Discovery support health plans as they evolve their payment integrity strategies?

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

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

Dan IantornoMerging AI and human intelligence for big recovery results
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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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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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White paper: Innovations in payment integrity for healthcare payers

White paper: Innovations in payment integrity for healthcare payers

Data mining, business intelligence, and analytics are at the core of today’s most successful payment integrity strategies

Today’s most successful payment integrity solutions are information-driven and automate many processes that are otherwise manual and time-consuming.

By combining advanced technology such as data mining and cloud computing, with information analytics and improved business processes, this new generation of “intelligent” payment integrity solutions enables health plans to more efficiently and effectively manage programs including eligibility, coordination of benefits, and subrogation.

Download this informative whitepaper today.

Discovery Health PartnersWhite paper: Innovations in payment integrity for healthcare payers
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