Evolving payment models and new technologies are supporting health plans’ efforts to implement more proactive, data-driven payment integrity solutions. We recently sat down with Subrahmanyam Mantha, Vice President, Payment Optimization for Discovery Health Partners, to discuss what’s in store for the future of payment integrity and how Discovery is helping clients make the transition from retrospective to prospective programs.
You’re the newest member of the Discovery leadership team. Can you share your experience prior to Discovery?
Over the past 20 years, I’ve held several positions in building payment integrity programs and supporting managed care organizations. This combination has given me a unique perspective of the entire claims lifecycle and where and when errors can occur. It also has afforded me insights into industry best practices from helping numerous payment integrity organizations set up audit programs and scale them in both post- and pre-pay.
What trends have you seen that are re-shaping payment integrity optimization strategies?
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.
What are some of the ways Discovery is helping clients transform their payment integrity approaches?
As industry needs change, we’ve stepped up our payment integrity capabilities with the addition of new talent, technology platforms, and analytical tools. We continue to expand our core offerings, adding new services and strengthening our cost avoidance competencies to help clients address their payment integrity challenges. Furthermore, Discovery is adding resources through strategic partnerships, and last year we acquired HealthMind, which brought us core payment integrity expertise and an integrated end-to-end-payment integrity application enabled by analytics and workflow that greatly expands our pre-pay solutions portfolio. With this new platform, we are scaling our payment accuracy capabilities and portfolio and building focused solutions around urgent care, home health, skilled nursing facilities, high-cost drugs, and more to help clients shift their focus to cost avoidance while still supporting recovery operations.
How is Discovery using data to evolve its 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. With the HealthMind acquisition, we’re well-positioned to support data-driven solutions and secondary code edit, provider audit, and data mining capabilities. This expands our ability to leverage 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.
Going into 2020 and beyond, our focus is to build on our technology foundation to provide full end-to-end payment integrity solutions for health plans that don’t have those resources in-house. We will also continue providing support for plans that have an internal payment integrity function.
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, it is clear that Discovery is that partner. Our 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 in 2020. Contact us today!