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 Complex billing processes, changing regulations, outdated and disparate data systems, and overlapping coverage all contribute to improperly paid claims.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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A year in review: top blogs from 2019

The new year is upon us and with it comes a new decade. It has been a decade of transformation for healthcare with regulatory changes, health system consolidation, healthcare consumerism, and new technologies that have forever changed the industry. 2019 has been a time of change and growth for Discovery Health Partners as well. Here are highlights from our most popular blogs of 2019 to remind you what we’ve been up to all year.

3 bad habits that are good for subrogation

In February, we talked about the three “bad habits” that can lead to successful subrogation: be unfair, ignore your members, and be pushy. In any other scenario, these tactics can get you into trouble. But for subrogation, being unfair requires that you not treat all cases equally. Ignoring your members is all about avoiding member abrasion. And being pushy involves aggressively identifying and verifying subrogation cases. Altogether, these tactics help improve the opportunity for quick and fair settlement of subrogation cases.

Why Medicare Advantage plans may be losing money on members with ESRD

In March, we featured a post about the challenges Medicare Advantage plans face with members with end-stage renal disease (ESRD). Though ESRD afflicts fewer than 100,000 people nationwide, the disease requires lifelong care—and a disproportionate percentage of medical expense. The blog discusses the gap in CMS premiums for ESRD members and what Medicare Advantage plans can do to better identify them.

It’s challenging to identify and restore underpaid ESRD premiums. Here’s how to solve that

Another popular blog continued the ESRD discussion, highlighting a systematic approach Medicare Advantage plans can take to restore ESRD premiums. This includes automating the process of sifting through data to identify potentially underpaid premiums and maximizing the 84 months that CMS allows plans to identify, investigate, and restore premiums. The blog identifies five key components of an effective ESRD program: analytics, investigation, remediation, restoration, and monitoring.

Subrogation: 3 ways SaaS can help

In July, we returned to the topic of subrogation with a discussion of how software-as-a-service applications can help. Plans are finding that combining SaaS applications with in-house expertise creates a more effective, data-driven approach for finding and validating subrogation recovery opportunities. Specifically, you can: 1) make in-house recovery more efficient and insightful; 2) gain accessible, easy-to-use, scalable, and secure solutions; and 3) do more at a lower cost.

Stay tuned to our blog for more insights on these topics and to see what 2020 has in store. You can also get the latest industry and Discovery updates by following us on LinkedIn and Twitter. Are you interested in learning how Discovery Health Partners can support your organization? Contact us today!

Discovery Health PartnersA year in review: top blogs from 2019
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Payment integrity emerging as a top cost reduction opportunity for health plans

As cost reduction continues to take center stage, healthcare payment integrity is in the spotlight. Increasingly, health plan executives are recognizing the power of payment integrity functions to add significant value to a health plan’s bottom line by improving the plan’s ability to recover or avoid improper claims payments and improve accuracy of premium revenue.

But, payment integrity is not always an easy landscape to navigate. Discovery Health Partners has had hundreds of conversations with health plans of every size and membership type across the country and a common theme that emerges is that while improving payment integrity is a priority, it is often one that is difficult to understand, manage, and achieve.

Over the last few months, Discovery has made a dedicated effort to understand what trends are shaping that complex payment integrity landscape. Our team of payment integrity professionals is experienced in not only identifying these trends, but also in understanding how they will impact health plans and shape financial performance and the member experience.

In a series of upcoming blog posts, Discovery will be exploring each of 2017’s payment integrity trends including:

  • Amplified focus on prepayment cost avoidance
  • Continued need for postpayment recovery
  • Heightened visibility around the importance of payment integrity with plan executives
  • Uncertainty about payment integrity performance by internal and vendor teams
  • Increased market consolidation and the impact on vendor selection
  • Growing interest in outsourcing the entire payment integrity function to a single vendor
  • Prioritization of business process outsourcing above software solutions

We also recently partnered with RISE to host a webinar on these trends. RISE, the Resource Initiative and Society for Education, is dedicated to ongoing outreach and education for health plans and providers. RISE offers complimentary webinars, white papers, a newsletter, peer user groups, and ongoing updates for plans and providers seeking the cutting-edge of healthcare information.

The webinar, now available on demand, features Discovery President, Paul Vosters, and VP of Strategic Development, David Grice, discussing each of our trends and answering the following questions:

  • Why should your plan increase the focus on payment integrity results?
  • How can your plan be on the cutting edge of these trends?
  • How can your plan mitigate some of the risks these trends present?
  • How is the latest healthcare payer technology changing the way plans approach data and security?
  • How should your vendors support you as you navigate the payment integrity landscape?

Check back often as we post more information about each of these trends. You can also download our 2017 Payment Integrity Trends white paper to read more.

Paul VostersPayment integrity emerging as a top cost reduction opportunity for health plans
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An enterprise approach to payment integrity technology

For many health plans, payment integrity is able to influence the bottom line in powerful ways. For payment integrity organizations (sometimes called cost containment), the new year is the perfect time to evaluate what has been working well and what can be done better and more efficiently. And often payment integrity technology is one of the areas that could use improvement. Payment integrity is traditionally a lower priority for IT support than core groups like Claims and Finance and as a result technology challenges arise including multiple sources of data, conflicting or inaccurate data, data integration challenges, manual workflows, multiple reporting systems, and on and on.

But creating a technology environment that can support payment integrity functions, whether that is claims recovery, subrogation, coordination of benefits, DRG, or others can bring IT and business managers together in their thinking. I recommend a “Payment Integrity Reference Architecture” that shows how payment integrity systems (such as recovery, case management, and reporting tools) integrate with enterprise IT to provide the backbone of a technology-enabled, data-driven payment integrity organization.

In a later piece I will describe this architecture more in-depth, but as you reconsider your technology environment and consider adopting a new Payment Integrity Reference Architecture, you will see  four specific layers of payment integrity technology emerge: Payment Integrity Services, Data and Analytics Services, Database Management Services, and Infrastructure Services.

The Infrastructure Services layer consists of foundational technology components that support all areas of the business and that are managed by corporate IT (includes networking, security, archiving, storage, and more). It’s important that this layer exists, but it is not directly relevant to the payment integrity discussion.

The next layer of our recommended Payment Integrity Reference Architecture is the Database Management Services layer. This layer contains data from internal groups and external partners – data that payment integrity groups need to use for their business processes. Some of this data will reside in core health plan systems, such as Finance, Claims, Enrollment, Pharmacy, and others. This layer usually consists of a corporate data warehouse that makes this core data available for all areas of the enterprise. From there, the data may flow into functional data marts, which allow for more flexibility to slice and dice data for functional analyses. As payment integrity functions mature within some plans, this layer may also include a Payment Integrity Hub, which establishes a system to coordinate recovery services across internal departments and external vendors in real-time.  The hub also provides visibility into work-in-progress for operations and forecasting.

Data and Analytics Services follows Database Management Services and refers to the technologies that help analyze, share, and report data. Within this layer are the analytics used to identify potential overpayments, duplicate payments, other party liability, other health insurance, etc. – opportunities to avoid or recover costs. In more mature organizations, this will include advanced analytic tools that look across diagnosis codes, dollar amounts, member histories, and many other data points to identify more potential recovery and savings opportunities.  This layer should also have reporting functionality.

The Payment Integrity Services layer includes the technologies that are specific to payment integrity functions.  Ideally, these tools should be relevant and useful across any area of payment integrity, whether coordination of benefits, subrogation, overpayment recovery, or others.  These are the tools that help automate some of the tedious or difficult tasks involved in payment integrity (for example, case identification, work assignments, work prioritization, and letter generation). They bring the automation, consistency, efficiency, and transparency that are cornerstones of a mature payment integrity function.

Throughout the evaluation process, keep in mind that your enterprise payment integrity efforts will benefit from technologies that can be used across payment integrity functions. For example, most payment integrity activities hinge on member eligibility information.  The goal should be to capture this information once and use it across all areas of payment integrity (and even with other areas, such as Claims and Finance). Likewise, a single Case Management tool should be able to service coordination of benefits as well as subrogation and any other area of payment integrity, so there is no sense in building or buying multiple versions of this functionality. For more detailed information, watch for my next published article, “Enterprise Approach to Payment Integrity Technology: Reference Architecture.”  Additionally, if you would like to gauge where your organization falls on the technology and data maturity model, see our blog “Enterprise Approach to Payment Integrity Technology: Using A Payment Integrity Maturity Model.”

John BairAn enterprise approach to payment integrity technology
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