Prepayment cost avoidance: A closer look at one of 2017’s top payment integrity trends

 

This post is part of an ongoing series about trends happening within the payment integrity space for healthcare payers. This series features contributions from Discovery Health Partners payment integrity experts discussing these trends, why they’re happening, and how they affect health plans. To learn more about all of the top trends, download our 2017 Payment Integrity Trends whitepaper.

Health plans see value in prepayment cost avoidance

Health plans are making a concerted effort to focus more of their payment integrity resources on avoiding inaccurate claims payments up front, rather than recovering erroneous payments on the back end. There is general agreement that this creates more value for a plan. When done successfully, prepayment cost avoidance allows the plan to avoid 100% of the claim cost (vs. the portion they can recover) and it reduces downstream administrative costs associated with recovery. I think we all can agree that having to work a claim multiple times is obviously more expensive than having to work it once.

In addition to financial benefits, prepayment cost avoidance can help health plans positively affect relationships with providers by reducing the burden on them to rework claims that are the responsibility of another payer. I recently saw a statistic that said providers incur an additional 20% – 30% of the cost of any claim they have to rework. Your providers would welcome a reduction in that cost.

Meanwhile, a focus on cost avoidance makes your members more accountable for ensuring that correct eligibility information is on file. Particularly in an area like coordination of benefits, members should feel more compelled to be proactive about providing the health plan with accurate, current information so their claims will be paid promptly without fuss.

Why the cost avoidance shift is happening now

In my experience, this is probably the biggest trend in the industry today. Why? Because of the vendor fees and administrative costs associated with recovering a claim that was paid incorrectly. At a time when health plans are very focused on reducing administrative costs and managing shrinking margins, executives are paying attention to every source of leakage.

While prepayment cost avoidance is not a new concept by any means, it requires a level of maturity within a health plan’s payment integrity operations that some plans are just now reaching. For one thing, more mature health plans typically have stronger data integration and analytics capabilities that allow them to look across multiple sources of information to make more accurate payment decisions quickly.

At the same time, their experience with postpayment recovery operations has given them some data to build a business case for the shift to cost avoidance. In my opinion, the largest barrier to cost avoidance until now has been the inability to justify the effort—cost, resources, technology, and vendors—in terms of a business case. There is no standard ROI or business model to work with, and every plan I’ve talked to uses a different approach. The fact is that health plans need to spend money to create a prepay cost avoidance capability and that means making sure the right people in the organization understand the value and business case for it.

For more information, see our infographic about capabilities required for successful prepay cost avoidance.

Coexistence with postpayment recovery

While prepay cost avoidance should be part of a plan’s payment integrity strategy, postpayment recovery must remain part of that strategy as well. The ability to make a prepayment decision can be hindered by the availability of information and the dynamic nature of eligibility and primacy information. Information often isn’t available fast enough to decide if a claim should be held or pended, so prompt-pay rules dictate that the plan must pay.

Meanwhile, member eligibility status and primacy are moving targets and constantly change, so payments are based on outdated information. For some payment integrity functions, like subrogation, costs can be avoided only on part of the whole recovery. In that case, only the first-party liability costs can be avoided, while third-party liability costs have to be paid.

Finding the right balance for your plan

In our view at Discovery, prepay cost avoidance and postpay recovery have to coexist as an integrated solution so you can follow the transaction through the whole lifecycle. The goal should be to find the right balance for your organization.

As health plans consider the proper balance of prepayment cost avoidance and postpayment recovery across their payment integrity programs, it’s important to remember that this is largely a cultural decision. A plan has to be ready to adopt prepay solutions, and a lot goes into that decision—including regulatory issues, technology capabilities, data availability, subject matter expertise, and the business case.

 

 

Discovery Health PartnersPrepayment cost avoidance: A closer look at one of 2017’s top payment integrity trends
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Discovery Health Partners announces webinar on trends in COB

A changing environment drives the reevaluation of current Coordination of Benefits practices

 

ITASCA, IL (April 17, 2017) –Discovery Health Partners, a provider of payment and revenue integrity solutions for healthcare payers, will host a webinar April 25, 2017, exploring the impact of changes in technology, information management, and best practices on Coordination of Benefits (COB). Titled “Coordination of Benefits: How the latest trends are impacting your plan,” the webinar features Discovery healthcare payment integrity experts Paul Vosters, President, and Kathy Cortez, VP of Operations.

During the webinar, the team will explore several trends that are changing the way health plans look at their COB functions and how plans can respond to improve plan performance. Attendees will learn about:

  • Growing complexity of managing member eligibility status and why it makes COB more challenging than most realize
  • Interest in prepay cost avoidance and how this road so paved with good intentions also has hidden landmines
  • The push to use data matching services to validate member eligibility
  • Increased focus on minimizing member abrasion in the COB process
  • New paths to improved data integration and automation and overcoming obstacles in the COB process

Seats remain available for this free webinar, which already has 125+ participants. To register, visit Discovery’s COB webinar page, where one can also sign up to review the webinar on demand at a later time.

 

About Discovery Health Partners

Discovery Health Partners, a division of LaunchPoint, offers payment and revenue integrity solutions that help health payers improve revenue, avoid costs, and enhance the member experience.  We offer a unique combination of deep healthcare expertise and analytics-powered technology solutions to help our clients improve operational efficiency, achieve financial integrity, and generate measurable results.  More information about our solutions, including Coordination of BenefitsEligibilityMedicare Secondary Payer Validation and Subrogation is available at www.discoveryhealthpartners.com.

 

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Discovery Health PartnersDiscovery Health Partners announces webinar on trends in COB
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Trends in healthcare coordination of benefits

A changing environment drives the reevaluation of current COB practices

 

Healthcare coordination of benefits (COB) has been a relatively unchanged process in health plans for many years, but advances in data management, analytics, cloud-based software, and digital communications are causing some interesting trends to take shape in the COB world.  These technologies, which have transformed many industries, are making their way into payment integrity processes, where health plan executives are working to address the challenges that cause inaccurate claims payments and to improve the processes that are used to identify, avoid, and recover those payments.

Inaccurate member eligibility and primacy data is often at the heart of payment issues. In fact, with multiple people and processes responsible for updating member status, it’s no wonder we don’t see more payment problems than we do. Too often, member eligibility and primacy are updated based on the narrow lens of a single person or process at a single point in time. Trying to avoid or recover claims based on this data often puts members and providers in the middle, causing abrasion and dissatisfaction. And as we know all too well, member abrasion can directly impact a health plan’s bottom line with members opting for different plans and affecting Star Ratings for Medicare Advantage plans.

As cost continues to be a core issue for health plans, it’s time to look at better ways of controlling costs, correcting payment errors, and protecting premium revenue while shielding members and providers from the fallout. Five key trends – or potential trends – are recurring topics of discussion, research, and tests among health plans and their vendors.  We recently discussed these trends in a webinar that you can watch on demand, “Coordination of benefits: how the latest trends are impacting your plan.”  The trends discussed include:

  • Momentum away from pay and pursue: As payers mature in their overall payment integrity technologies and best practices, they are working to shift more of their COB efforts to avoiding inaccurate claim payments vs. recovering them on the back end. Pre-pay cost avoidance can yield a 40% increase over recovery, so the business case speaks for itself. However, this more proactive approach requires more sophistication in areas of data integration and analytics to quickly and accurately identify claims that are not the plan’s responsibility.
  • Emergence of “matching” services: There seems to be a push among large health plans to require vendors and other health plans to leverage data matching vendors for eligibility validation. We find that this data is most useful for identifying “leads,” or potential cases of other insurance that can be further investigated. Plans can then focus their COB resources more intelligently for a better return on their efforts.
  • Attempts at using analytics: Our industry has a growing appetite to incorporate analytics into COB processes to identify members with the highest probability of other coverage.  Increasing the use of analytics throughout payment integrity generates many potential benefits, including reduced cost of COB and reduced member abrasion. While many health plans are making small steps in this area, there is still a long way to go.  Rules-based analytics can tell us, for example, that a member who is 65 should be on Medicare and we should investigate whether that is the case. But beyond that, predictive analytics and machine learning technologies can help us look at multiple factors (age, demographics, and disease categories) to more closely pinpoint members that may require COB.
  • Balancing COB efforts with risk of member and provider abrasion: Health plans are demonstrating increased frustration with traditional methods of member and provider outreach, which can result in abrasion. As a result, plans and their vendors are looking at new ways to get the information they need while communicating with constituencies on their terms. This may include using a combination of traditional communication channels as well a member and provider portals, mobility, and automation (such as using 270/271 transactions) to exchange information in more productive, cost-effective ways.
  • The need for data integration is outpacing the industry’s ability to provide it: The trend here is simply that the industry is not evolving fast enough to meet the data needs of all parties involved. Bringing together data from a variety of sources, including claims, social media, Section 111, CMS, states, providers, and much more, is necessary to support areas of eligibility, analytics, and pre-pay cost avoidance. But as an industry, we are still largely unable to sustain the high volumes of data, integrate it properly, ensure its accuracy, and access it fast enough to inform payment decisions.

To learn more about these trends and some ideas for moving forward, listen to our on-demand webinar. You can access the webinar from our web site.

Kathleen CortezTrends in healthcare coordination of benefits
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Webinar: The latest trends in healthcare Coordination of Benefits (COB)

The latest trends in healthcare Coordination of Benefits (COB)

How are the latest COB trends impacting your plan?

Discovery Health Partners payment integrity experts discuss the benefits and challenges of today’s COB trends. In this free webinar, we’ll discuss:

  • Why the complexity of member eligibility status makes COB more challenging than most realize
  • How the road to pre-pay cost avoidance is paved with good intentions and hidden landmines
  • The push to use data matching services to validate member eligibility
  • Ideas to minimize member abrasion in the COB process
  • Obstacles to improving data integration and automation in the COB process

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

Discovery Health PartnersWebinar: The latest trends in healthcare Coordination of Benefits (COB)
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Infographic: Five trends in healthcare Coordination of Benefits (COB)

Five trends in healthcare Coordination of Benefits (COB)

Take your COB program to the next level

Healthcare coordination of benefits has been a relatively unchanged process in health plans for many years, but advances in data management, analytics, cloud-based software, and digital communications are causing some interesting trends to take shape in the COB world. Health plans increasingly use this technology to improve processes that identify, avoid, and recover inaccurate claims payments.

This infographic covers the top trends impacting Coordination of Benefits today:

5 COB trends infographic - Discovery Health Partners

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.

Discovery Health PartnersInfographic: Five trends in healthcare Coordination of Benefits (COB)
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