The known unknowns of healthcare and health policy

It seems like eons ago that we were all out and about—mask-less and mingling with others. But things have certainly changed in the months since the pandemic struck. We’ve had to make some major shifts in our lives, and phrases like social distancing, virtual learning, and Zoom calls have become part of our everyday vocabulary.

Our world has changed a fair bit—especially so in healthcare

At Discovery Health Partners, we have transitioned to a fully remote workforce—as many of you have—and we are getting pretty good at navigating this new normal.

In our ever-evolving landscape, we’re thinking about what the next 12 to 18 months may look like and what unknowns we face. Here are some of the trends we’re watching and the implications they may have:

  • Reduced elective procedures during the pandemic—and how it affects member acuity
  • Increase in the telehealth adoption—and payment integrity issues surrounding appropriate telehealth billing patterns and coding
  • Reduced motor vehicle traffic during the pandemic and potential long-term reduction in motor vehicle traffic from a shift to working from home—and how this affects subrogation activity

We recently hosted a virtual client council meeting to discuss the future of healthcare and payment integrity with healthcare policy analyst Susan Dentzer as our keynote speaker.

In her “Health policy and the 2020 elections: what’s ahead?” keynote, Susan shared her fascinating perspectives with us about the “known unknowns” we can expect to encounter in this highly uncertain time.

Expected changes in health insurance coverage

According to Susan, we’ve never seen anything like our current set of circumstances any time before in modern history:

  • Known knowns: COVID-19, a weakened economy, ~30 million jobless, more uninsured
  • Known unknowns: the course of the pandemic this fall and winter, the outcomes of presidential and congressional elections, the course of economic recovery
  • More known unknowns: depending on the outcomes of all the above, what health policies will be on the table? What will or can be enacted?
  • Unknown unknowns: how will 2021 overall look in relation to 2020—in almost every respect?

She shared her insights about the impact of the coronavirus on the economy (“covidomics”) and what we could possibly expect to be the future of healthcare.

One of the biggest changes we can expect to see, according to Susan, is the rise in the uninsured rate. Even before COVID hit, she says, there were forces underway that would affect health law changes.


Projections show 3.3 million of those people will regain employer-sponsored insurance by being added to a family member’s policy, 2.8 million people will enroll in Medicaid, and 600,000 people will enroll in the individual market, mainly via the Affordable Care Act’s marketplace. Still, 3.5 million people will become uninsured.


“In a fair number of states,” Susan commented, “we’ve had at least modest rises in the uninsured rate. We knew that we were going to have this uninsured problem even before the pandemic, and then the pandemic hit.”


An estimated 48 million nonelderly people in the United States will be part of a household in which someone loses a job due to COVID-19, based on an assessment of pandemic-related job loss.


She pointed to Urban Institute research on coverage projections in the wake of pandemic-related job loss, in which 48 million people live in families with a worker who will have experienced COVID-related job loss in 2020.

“The Urban Institute estimates are, when you net all this out, about 3.5 million more people are likely to become uninsured as a consequence of the pandemic,” Susan said. “We had a big pool of uninsured, and now we’re adding potentially 3.5 million more people who are dreadfully uninsured as a consequence of this pandemic. The implication of this rise in uninsured population will likely be….???”

Rising Medicaid enrollment strains states’ budgets

Susan also discussed with us the impact of rising Medicaid enrollment on states’ budgets—already stretched too thin—and the toll that Medicaid providers are experiencing. “Medicaid enrollment has risen, and we have states in an enormous amount of fiscal difficulty at this point,” said Susan. “The degree to which that particular set of increments to Medicaid can be sustained is really in doubt. In some cases, the states’ revenues are so damaged that the state has compensated by cutting payments to providers.” This is not a sustainable solution by any stretch—some providers will stop accepting Medicaid, while others may continue to accept Medicaid but provide less care. Ultimately, this could create an inability to access quality care for a large segment of the country’s population.

And the challenge to state Medicaid programs will not get any easier in the near term. According to the Center on Budget Policy and Priorities, the unemployment rate will average 10.6 percent over 2020 and still be at 7.6 percent by the end of 2021. That would be the highest annual unemployment rate since the 1930s. Coupled with that, the U.S. economy is declining more sharply compared to the Great Recession of 2008. Certainly, Medicaid will be a key central issue over the coming months as states devise strategies to provide healthcare coverage to more people, control the pandemic’s impact on individuals’ health coverage, financially support providers’ viability, and balance their budgets.

What’s ahead

As we all know, a host of other healthcare issues remain—affordability, regulation of pharmaceutical prices, value-based payments, data sharing, and price transparency. Amid these multiple uncertainties, we will continue to monitor how the pandemic has transformed the healthcare policy landscape and share our insights with you.


About Susan Dentzer

Susan DentzerSusan Dentzer is one of the nation’s most respected health and health policy thought leaders, top healthcare keynote speaker, a frequent commentator on television and radio, including PBS and NPR, and an author of commentaries and analyses in Modern Healthcare, the Annals of Internal Medicine, and the New England Journal of Medicine. She is also the editor and lead author of the book Health Care Without Walls: A Roadmap for Reinventing U.S. Health Care.

Jason BrownThe known unknowns of healthcare and health policy
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How the ESRD process works. And why it sometimes doesn’t.

Medicare Advantage plans don’t typically have a large population of members with End-Stage Renal Disease (ESRD). In our work with dozens of plans, we see about 5% of members with ESRD, a condition where there is permanent and almost complete loss of kidney function.

These few members, however, can have a big impact on a plan’s financial health if the Centers for Medicare and Medicaid (CMS) are underpaying premiums for these members. And especially if CMS has been underpaying for a length of time.

The average cost to treat a patient with ESRD can run well over $60,000 a year because members may require dialysis several times a week. To offset this higher cost of care, CMS typically pays health plans a premium of $7,100 for managing members with ESRD, compared to a premium of $815 for non-ESRD members. When you multiply the gap between non-ESRD premiums and ESRD premiums year over year, having the wrong ESRD status for a member can be quite costly to your plan.

Hear from the experts

Discovery ESRD Premium Specialist Janayth Carmona sits down with colleagues and ESRD Premium Restoration experts Alex Projansky and Denise Ytsen to discuss their experience working with inaccuracies in members’ ESRD statuses—and why it can be so costly to your health plan.

Ongoing inaccuracies can mean that your plan is losing out on millions of dollars

Determining the cause of the error is time-consuming—and can be complicated—for health plans.


When you multiply the gap between non-ESRD premiums and ESRD premiums year over year, having the wrong status for your ESRD members can cost your plan millions.


Let’s take a look at how the ESRD process ideally works:

  1. The ESRD patient visits a dialysis clinic for treatment.
  2. The dialysis clinic or submitting authority fills out form 2728 (completely and accurately) and submits this to CMS through CROWNWeb, the data-management system that allows Medicare-certified dialysis facilities to safely submit facility and patient data to CMS.
  3. CMS is alerted to the patient’s ESRD status—and an ESRD indicator flag is turned on that will adjust the premium for that patient.
  4. Your plan then receives a higher premium for covering these patients.

In some situations, however, the process breaks down:

  • Members have ESRD diagnoses that your plan never knew about
  • The dialysis clinic or provider doesn’t complete the 2728 form or sends incomplete or incorrect forms
  • The clinic saves the form in CROWNWeb but doesn’t hit “submit”
  • Flag are temporarily turned off and not turned back on—for example, because the member went to hospice for a period of time
  • CMS fails to set the flag or had inaccurate dialysis start dates

Discovery is adept at navigating these complex processes and restoring premiums

Discovery can help your plan identify members with missing ESRD statuses and work to correct the errors at the source—by working directly with the submitting provider and CMS.

To begin our restoration process, we use the plan’s historical claims data and multiple data sources to identify claims diagnosis patterns. We look at the detailed membership files to see if that ESRD flag is present. If it’s not, we reach out directly to the dialysis center and, if needed, get the 2728 form resubmitted properly.

This can sometimes prove challenging as the dialysis center’s main focus is on patient care and not necessarily on ensuring the 2728 form has been completed accurately and submitted through CROWNWeb appropriately. So, our team will explain the importance of following CMS guidelines and will work with the dialysis center from start to finish to ensure the form is accurately re-submitted through CROWNWeb. We also coordinate with CMS to make sure that flag gets turned for the appropriate timeframe. Finally, we track the CMS Monthly Membership Report (MMR) updates and continuously monitor MMRs to ensure the flags remain on, as necessary.

Let us start reviewing your records

Discovery Health Partners can help find value for any size health plan, utilizing an 84-month non-intrusive lookback that restores actual premium dollars based on corrected ESRD flags. Plus, based on corrected ESRD flags, our lookback work ensures that future premiums are paid accurately for members with ESRD.

Learn more about Discovery’s ESRD Premium Restoration solution.

Alex ProjanskyHow the ESRD process works. And why it sometimes doesn’t.
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Three benefits of physician oversight in clinical audits

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.

Moira Dolan, M.D.Three benefits of physician oversight in clinical audits
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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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Trends that are re-shaping payment integrity strategies

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.

Diane AkramiTrends that are re-shaping payment integrity strategies
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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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Webinar: COVID-19 roundtable | Helping you get payment integrity done

COVID-19 roundtable: Helping you get payment integrity done

What you can expect from this webinar

The COVID-19 pandemic has quickly and drastically changed the way we’re living and working these days. This webinar helps health plans solve payment integrity operational challenges associated with the COVID-19 pandemic.

  • Learn more about working from home, security infrastructure, and productivity
  • Gain insights from Discovery’s own experience transforming to a remote workforce company over a year ago

Use the quick form on the right to view the webinar on-demand.

Discovery Health PartnersWebinar: COVID-19 roundtable | Helping you get payment integrity done
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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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How COVID-19 trends are impacting payment integrity

At the close of 2019, healthcare predictions echoed the challenges of years past: complex billing processes, changing regulations, and rising healthcare costs. It was no surprise that health plans would continue to tackle these long-standing issues that contribute to improper claims payments in 2020. Little did we know, though, that payers would find themselves facing these challenges in very unexpected ways amid a global pandemic.

Health plans, bracing for the full impact of COVID-19, will need to find ways to navigate the uncharted course―a course that is no longer focused primarily on cost efficiency, quality, and delivery standards. Rather, a new course is taking shape that centers on safety, performance, and demand.

Promoting safety and well-being

In response to the COVID-19 pandemic, most states have issued shelter-in-place orders, requiring non-essential businesses and staff to work from home. Health plans are now faced with either remaining open as a critical operation or moving operations to newly established remote environments. For some plans, the transition from offices to mandatory work-from-home settings can present initial challenges (e.g., operational requirements, data security). As these challenges are addressed, payers are also working with their provider partners to increase access to care while protecting providers and the community. For example, the expansion of remote care and monitoring services help support social distancing and reduce the risk of exposure to COVID-19.

Facing financial performance impacts

The total number of COVID-19 cases continues to rise, prompting healthcare associations to recommend the suspension of elective surgeries and procedures to maintain sufficient capacity to treat patients and minimize risks of exposure. As those types of claims decrease, we anticipate a spike of high-dollar inpatient claims to treat individuals affected by COVID-19. In fact, a recent analysis by S&P Global estimates a severe COVID-19 pandemic could cost U.S. health plans more than $90 billion in medical claims alone1. While several major health plans have recently pledged to waive costs associated with COVID-19 treatment, we can expect these costs will cause health plans to experience significant financial stress.

To offset these great costs, we recommend health plans with large Medicare populations to look to other areas to positively impact revenue. For example, Premium Restoration (the recovery and protection of premium revenue) is one way to maximize financial performance in 2020 while not disrupting COVID-19 initiatives.

Increasing demands on healthcare organizations

It’s no surprise that as COVID-19 cases continue to grow, so are claims for testing and treatment and, more importantly, high-dollar inpatient stays. To this end, the Centers for Medicare & Medicaid Services (CMS) has issued new guidelines that lift restrictions and offer more flexible coverage options (e.g., tele-health). The American Medical Association (AMA) has also provided special coding advice to help healthcare professionals during the COVID-19 public health emergency. And in an effort to help ease the strain the pandemic is creating for healthcare providers, health plans are suspending reviews on COVID-19 related claims

With so many rapidly changing policies and requests, the regulatory burden is mounting for both health plans and providers alike. It will be more important than ever to make sure your plan has the correct member eligibility to avoid months of catch-up. Given these uncertain times, we highly recommend plans have a strong coordination of benefits (COB) program in place to ensure accurate and updated eligibility data while driving future cost avoidance.

Contact Discovery Health Partners today to find out how we can help you with your payment integrity efforts amid COVID-19.

Access the latest COVID-19 information from our COVID-19 response page.

Discovery Health PartnersHow COVID-19 trends are impacting payment integrity
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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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