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payments abound in healthcare, many of which stem from eligibility errors made as a result of multiple data sources, outdated technology, manual processes, and members with other insurance coverage.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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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.
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Three ways to modernize your COB approach

When health plans think of Coordination of Benefits (COB), the hassles of managing spreadsheets, letters, and phone calls come to mind. These painstaking manual and error-prone methods for identifying other insurance, validating coverage status, and recovering incorrectly paid claims can negatively affect your internal efficiencies, your provider and member relationships, and ultimately, your bottom line.

According to new research, waste accounts for about 25% of U.S. healthcare spending or $760 billion to $935 billion per year –with administrative complexity cited as the greatest source of waste.1 In addition, as many as 15% of all health plan members may hold other insurance coverage.2 Compounding these challenges are continual changes in membership, such as an aging workforce that is eligible for both employer plans and Medicare, and outdated claims processing environments that are ill-equipped to support growing and siloed data.

The convergence of these trends calls for a modern approach to managing your COB program. In today’s competitive marketplace, plans must have the right people, processes, and technology in place to effectively integrate data sources, look at member eligibility holistically, and determine the most successful indicators or combination of indicators of other coverage.

Here are three ways you can improve your COB program and cut down time, money, and paper:

#1: Increase recoveries with technology

There is great manual effort in traditional approaches to COB. Typical COB efforts involve tedious, time-consuming research and member questionnaires and calls—all of which are often ineffective and create member dissatisfaction. New technologies, such as machine learning, predictive analytics, and rules-based analytics, help identify members who have other forms of insurance and other factors that might mitigate inaccurate payments.

#2: Improve cost avoidance

One of the most important keys to success in the modern approach to COB is avoiding inaccurate payments in the first place. Proactive approaches to COB leverage sophisticated data integration, data mining, and data analytics. With technologies that quickly and accurately identify claims that are not the plan’s responsibility, a health plan can resolve claims before paying a dime.

#3: Focus on member and provider satisfaction

Traditional approaches to COB put members and providers in the middle, causing abrasion and dissatisfaction. The modern approach to COB requires that plans and their vendors look to new ways to get the information they need while communicating with providers and members on their terms. This may include using a combination of traditional communication channels, as well as member portals and automation to exchange information in more productive, cost-effective ways.

Core elements of a successful COB program begin with data sources, driven by sophisticated machine learning algorithms to create leads, and matching capabilities which all stand on the foundation of human talent. Without the right team, the technology does not yield the same results.

Discovery’s COB program encompasses all these components and offers both cost avoidance and post-payment, delivering considerable incremental recovery opportunities with minimal disruption to operations. Our COB program uses machine learning-based data mining and modeling to:

  • Identify additional instances of other insurance coverage
  • Validate coverage status
  • Recover any claims paid in error without any disruption to existing claims adjudication processes or existing internal COB validation and recovery efforts

The modern guide to COB - Get the eBook

1 JAMA, “Waste in the US Health Care System: Estimated Costs and potential for Savings,” October 7, 2019
2 Discovery Health Partners’ experience.
Ron JonesThree ways to modernize your COB approach
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eBook: The modern guide to COB

eBook: The modern guide to COB

Manual and error-prone Coordination of Benefits processes contribute to millions of dollars in annual waste

Save time, resources, and paper with advanced technologies that can help you transition from cost recovery to cost avoidance.

Download our eBook and see how a modern COB approach can help you:

  • Increase recoveries
  • Improve cost avoidance
  • Reduce administrative costs
  • Achieve greater member and provider satisfaction

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Maximizing your COB processes with integrated technology

Primacy and eligibility errors can lead to serious losses and expenses. By some estimates, a third of paid health claims contain errors, and as many as 15% of members have other insurance—representing a staggering $1 trillion in annual waste1. Paying for claims due to incomplete or inaccurate member eligibility not only costs your plan millions in higher payouts and administrative costs, these errors can also generate substantial downstream administrative costs and greatly impact your provider and member relationships.

While Coordination of Benefits (COB) is a common occurrence (the process of determining which plan pays for what portions of a claim), the challenges associated with addressing other insurance retrospectively lead to increased administrative costs and payouts. Plans must go beyond the traditional process of post-payment recovery to an expansion of prospective processes that identify potential primacy conflicts while still in the pre-payment stage.

Things to ask as you evaluate your COB processes:

  • How can we identify more instances of other coverage and maximize our savings from cost avoidance and recovery of overpaid claims?
  • Do we have the data mining technology and expertise to identify Medicare or other commercial coverage?
  • How do our COB processes compare to industry best practices?
  • How do we transition our COB program from recovery to cost avoidance?
  • How can we minimize member and provider abrasion while coordinating benefits?

Data mining, business intelligence, and analytics are at the core of today’s most successful payment integrity strategies, including COB. As part of our connected payment integrity approach, Discovery’s COB solution automates data integration across multiple sources, bringing it all together in a single database that allows for quick and accurate identification of claims and provider responsibility. This means frequently refreshed data with up-to-date information. In addition, predictive analytics and machine-learning technologies analyze and prioritize data, allowing us to flag and take a closer look at members with a high probability of having other coverage. Our goal is to identify and address primacy issues at the earliest possible stage—improving claims payment accuracy, building stronger relationships with providers, and reducing administrative expenses.

To learn how Discovery Health Partners has helped health plans drive cost savings and millions of dollars in recoveries, download our COB case study or visit our Coordination of Benefits solution page.

1 The Office of the Actuary in the Centers for Medicare & Medicaid Services (July 2015)
Ron JonesMaximizing your COB processes with integrated technology
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Case study: Coordination of Benefits (COB) for healthcare payers

Case study: Healthcare Coordination of Benefits (COB)

COB solution drives measurable cost savings and millions of dollars in recoveries for three health plans

As these three cases demonstrate, the Discovery Coordination of Benefits solution was designed specifically to address critical COB challenges, with an emphasis on flexible delivery models that support our clients’ unique requirements.

Harnessing the power of our Healthcare Analytics Platform, our COB solution enables fast and accurate identification, investigation, case management, dashboards, and analytics, as well as insourced or outsourced delivery.

Download this insightful case study today.

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Choosing the right COB partner for your plan

At any given time, between 8-15% of a health plan’s membership is covered by another plan, resulting in incorrect eligibility information that could be costing your plan millions in incorrect payments, time, and resources.

Disparate data, siloed information systems, and multiple moving parts all contribute to incorrect eligibility information and improper payments. To identify instances of other health insurance, your plan needs access to multiple data sources and the ability to verify state, CMS, and CAQH data—all of which add more time and resources. Even if done correctly, there is still a chance your plan is leaving money on the table. So what can you do and how do you find the right partner to supplement your team?

Choosing the right partner has never been more important or more daunting. A growing number of vendors claim to use leading-edge technology such as data mining, artificial intelligence, and machine learning. But what does this mean to you and your health plan?

To help you choose the right COB partner, here are some key factors to consider:

  • 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? Or are they inflexible to change?
  • Technology: Is the vendor using cutting-edge 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 you plan line up with the vendor’s other clients? Will you be a priority for them?

 

To learn how Discovery Health Partners can help support your COB initiatives, visit our Coordination of Benefits solution page or open up the contact form to the right.

Kevin McDonaldChoosing the right COB partner for your plan
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White paper: Proactive COB strategies

White paper: Proactive COB strategies

Cost avoidance is more than just a way for Medicare Advantage plans to improve their bottom line; it gives them a competitive edge in a crowded market.

Even as recovery operations continue to thrive, health plans have sharpened their focus on prepayment technologies that can manage costs, optimize claims payments and ensure the care patients need is appropriately covered. As health plans invest in a technology driven approach that incorporates new, more robust data sources into their COB processes, they must find the right balance of recovery and a proactive approach that looks to solve root cause of incorrect payments that result from incomplete or inaccurate coverage information.

To stay competitive and meet consumer needs, Medicare Advantage plans may need to offer low-cost supplemental benefits that help them attract new members. A proactive COB strategy that addresses primacy order and eligibility can provide the means to fund these additional offerings.

Fill out the form to download this informative whitepaper today.

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4 ways technology is shaping the future of COB

When we think of the future, we tend to think of things like space travel, the next presidential election, and what we’ll have for dinner later tonight. That’s all very interesting, but what about the future of…healthcare coordination of benefits? Okay, maybe it’s not as exciting as humans living on Mars or Oprah for president, but there are some interesting things happening in COB that are changing the way health plans approach this age-old process. Here are four ways technology is changing how we think about COB.

1. A data-driven approach

What do we mean by a data-driven approach? At the most basic, it means to use all relevant and available data sources to identify members with other insurance who could have recoverable claims. This isn’t necessarily futuristic. Don’t we all use multiple sources for this now – eligibility and claims files, MSP files, CAQH data, State Medicaid files, Section 111 reporting?

For the most part, yes. But HOW are we looking at this data? Is it a team of investigators pouring over Excel spreadsheets and printed files, trying to draw conclusions? Do they waste a lot of time investigating claims that aren’t recoverable? Are they calling members to get the information they need? Do they miss potential opportunities to recover claims?

It’s not just a matter of having the data. What matters as well is the speed with which we’re able to get that data. As an industry, when we think about the future of COB, we need to think about fast, automated data integration across multiple sources. In other words, bringing all that data together into a single database that can be queried to quickly and accurately identify claims that are likely to be another provider’s responsibility (see #2 below).

We need to think about refreshing this data faster so we have the latest information at our fingertips at all times so we can make decisions earlier in the process that would allow us to maximize our recoveries and up-front cost avoidance. And we need to think about emerging data sources that can help improve the accuracy of the member profile. For example, is there an opportunity to mine social data (e.g. Facebbook posts) to learn of qualifying life events?

If you really want to get into the weeds about data integration in the health insurance industry, check out this great blog post by data integration company Veristorm.

2. Analytic focus

Wikipedia defines analytics as the “discovery, interpretation, and communication of meaningful patterns in data.” From a COB perspective, we can apply analytics to the data we have to identify members with the highest probability of having other coverage.

Most in the industry are at least dipping their toes into the analytics pool. Much of it today is “rules-based” analytics. For example, we’ll create a simple business rule that says when a member turns 65, they should be on Medicare. This yields information that tells us to analyze whether those members are on Medicare.

Analytics is where things could get really interesting for COB and despite much hype, the industry is just getting started here. When we apply advanced analytic techniques like predictive analytics, we can quickly look at multiple factors (such as age, demographics, disease categories, and much more) to more closely pinpoint members that may require COB. Taking it a step further, machine learning technologies would automatically determine the most successful indicators (or combination of indicators) of other coverage and automatically update the analytic models to reflect that learning.

Even to me, this all sounds very complicated and daunting. For most organizations, leveraging analytics to drive improvements in payment integrity is more of an evolution than a revolution. I suggest starting small. For example, start with your internal claims and eligibility data and see what you can glean from that. Find out what works and build on it from there. There are several benefits to advancing the use of analytics in healthcare COB, including:

  • Reducing the cost of COB (less manual effort, less time investigating false positives)
  • Reducing member abrasion (more accurate identification means less validation work)
  • Increasing cost avoidance (denying claims that are another plan’s responsibility)

3. Case management application

Full disclosure: this point is somewhat self-serving because Discovery has a proprietary case management application that we use to deliver COB solutions for our clients. But I feel so strongly that this current capability is also critical for the future of COB, that I couldn’t leave it out.

Though COB is a seasoned, well-oiled machine for most health plans, it does encompass many steps and individual processes. It also demands a “paper trail” to capture all the information that is discovered throughout those processes. A case management application is the perfect way to guide your team through your specific process, while capturing and sharing critical data along the way.

This single data repository should be used to drive all case-related activity so you have fast access to high-level and detailed case data. Our Discovery Case Manager allows you to see activity history, planned activity (case diary), and notes (about investigations, status, phone calls, etc.). You also can identify and manage rebill activity at the provider and claim level, and store and update employer and other insurance information and payer order.

Having all this detail in one place provides you with the digital paper trail that not only supports your recovery work, but that could also allow you to make future claims payment decisions more quickly and accurately. And this brings us to our final point below.

4. Reporting tools

As COB organizations become more sophisticated about their use of data and analytics, their reporting capabilities will improve. Dashboards and reports can be automatically created based on data in your case management tool and/or analytic tools to provide you with easy-to- see information about your membership, COB opportunities, and results.

Having access to more accurate data, the organization will be able to better identify members with potential other insurance, improve the accuracy of forecasting, and analyze trends. Reporting functionality through dashboards and/or standard reports is critical for understanding how well your COB process is functioning and to identify areas for improvement. Even with limited data and analytic capabilities, you can begin to experiment with reports. Important data to track for COB includes:

  • Case inventory
  • Case pending
  • Case status
  • Recoveries

The bottom line is that, wherever your COB program is in terms of technology maturity, there may be opportunities to step that up and boost the performance of your program even further. Most COB programs struggle with issues such as ongoing eligibility/member status errors, member and provider abrasion, and resource constraints. Technology-enabled COB can help address these and other challenges that may be standing in the way of your best year yet!

Learn about more COB trends in the infographic, Five trends in healthcare Coordination of Benefits.

Janetta Dean4 ways technology is shaping the future of COB
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Video: Drive stronger results with technology-enabled COB

Drive stronger results with technology-enabled COB

A technology-enabled approach to Coordination of Benefits can help identify additional opportunities to save and recover while minimizing member and provider abrasion

For more information

Please visit our Coordination of Benefits page or open the contact tab on the right to get in touch with a Business Development Associate.

Chelsea GerschVideo: Drive stronger results with technology-enabled COB
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