Data Mining FAQs

We’ve compiled answers to some of the common questions we get from health plans as they look to build or expand data mining capabilities for their organizations.

Is there a certain dollar threshold for claims you’ll review?

Discovery works closely with clients to mutually agree on an overpayment threshold. The majority of our clients set the threshold at $50-$100.

Do you rely only on algorithms or only on manual review for data mining?

Discovery relies on both algorithms and our experienced Data Mining team to identify overpayments. The algorithms drive the sample of claims from which the auditors will filter and sort to identify/validate the overpayments that have the highest scored accuracy, dollar value, time sensitivity, etc. Every overpayment we identify is 100% validated in the client system. Overpayments are never sent out the door without “human touch,” which minimizes the amount of oversight required by the client.

How long before an identified data mining concept can be moved in house?

This varies depending upon the root cause of the overpayment, but we partner with our client’s in-house team every step of the way. For example:

  • A contract load error can typically be resolved in a shorter period of time
  • Decimal point error on surgical case rate ($50,000.00 vs. $5,000.00)
  • A claims processing error that is contrary to policy design and intent may require a longer period of time for resolution
  • Claims processing allowing ungrouped surgical procedures to pay at total claim percentage of billed charges vs. line item percentage of billed charges

Is there a standard integration process for Data Mining services?

Discovery does not use a standard integration process; we customize the process based on each client’s specific requirements. Our flexible integration approach minimizes our client’s time and resources—we configure our workflows and file transfers based on the client’s custom rules and codes, utilize the client’s existing specifications and data feeds, and accepts the client’s data in its existing format.

What’s the best way to approach data mining without harming our provider relationships?

Through our work with dozens of health plans, Discovery has found that the most effective way to introduce data mining is through a phased approach. This approach allows us to help health plans balance overpayment identification while maintaining positive provider relationships. Discovery uses a three-phased approach.

Phase 1: Global concepts

These are “black and white” overpayments with little to no room for contract or regulatory interpretation. Global concepts are applicable to all lines of business. The most common examples include:

  • Duplicate payments
  • Excessive charges
  • Excessive units

While all adjudication systems deploy edits to prevent these global concept overpayments from occurring, they are not always simple to catch and prevent. As an example, duplicate payment errors are more than just “the same claim paid twice.” Duplicates can occur across a subscriber and dependent, two different provider NPIs under the same tax ID, or multiple interim claims with overlapping dates of service. Discovery deploys multiple queries to identify all possible scenarios at both the header-claim level and the detail-line level.

Phase 2: Contract & policy concepts

These concepts are based off billing guidelines and require an analysis of contract terms to develop and deploy. Contract and policy concepts include:

  • Medicare pricing for all claim types (inpatient, outpatient, rehab, etc.), including any retroactive updates from CMS
  • Medicare readmissions and transfers
  • Modifier reductions, including assistant surgeon/non-physician practitioner reviews and practitioner/surgery validation
  • Multiple procedure reduction, including surgery and imaging services

Phase 3: Contract deep-dive

The last phase introduces custom concepts based on a client’s specific provider and plan contractual language. Below are some example targets:

  • Correct reimbursement for combinations of observation, emergency room, and surgery
  • Stop-loss provisions
  • Implant and high-cost drug thresholds
  • Carve-out validation

Not all our clients move through all these phases. Some decide to stay in Phase 1 and may approach Discovery if they have a specific need. Others will give Discovery full access to contracts and policies. There is no right or wrong approach—we are flexible and tailor our Data Mining services to the exact needs of each client.

Discovery Health PartnersData Mining FAQs
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Provider-sponsored health plans in the era of COVID

Our Discovery Expert Perspectives series brings you thoughts, advice, and opinions from experts across the healthcare ecosystem. Discovery maintains an ongoing partnership with these experts to enrich our understanding of the industry and shape solutions that deliver profound value to our clients. We are proud to share these experts’ unique perspectives with you.


When the pandemic hit in early 2020, it created many challenges within the healthcare industry, and now another wave is stressing healthcare systems again. While providers have been strained by capacity and economic issues, health plans have fared better financially. When a lot of preventative and elective procedures were postponed, many of the payers were profitable in the earlier part of the year and are waiting to see how much of the normal claims volume returns in the latter part of this year.

Provider-sponsored health plans (PSHPs), many of which are part of integrated delivery systems, have some of the same challenges as other payers but have some different ones as well. Many of these plans have value-based payment arrangements with their owner systems, which has been been a more predictable source of income for the providers than fee-for-service revenue. The pandemic may accelerate the trend to move more providers into risk arrangements.

Capital investments have always been a challenge for PSHPs, and now more than ever, that may be a limiting factor as many of their owners are trying to preserve capital. One health system, which has created a Management Services Organization (MSO) to leverage its health plan expertise to help other systems, decided to abandon this strategy. The capital investment that the MSO needed was more than the system wanted to spend given the uncertainty of COVID. This constraint on capital could also impact health plans that want to expand geographically or by product line.

Large payers have capital on hand, and this could prompt them to look for acquisitions. A provider-sponsored health plan might be an attractive target. Will system owners view their health plans as a strategic asset for their future or will they be tempted to cash in on this asset?

There have been some system mergers, some of which involve health plans. Combining the organizations can strengthen their plans. These include Sentara Healthcare and Cone Health and, more recently, IntermountainHealthcare and Sanford Health.

PSHPs are in different lines of business, and each of these will experience different challenges related to COVID and the health and economic impact of the pandemic. For the health plans that offer Medicare Advantage, their elderly population is most at risk for complications from the virus. How are MA plans identifying the risk factors for this elderly population? For those members that have contracted the virus, some will have long-term complications. PSHPs can work with their health systems to address these needs.

As we find ourselves in the midst of the fall flu season and an increase in COVID rates, parts of the economy are recovering, but there are other segments that are not. There is a concern that the economy will stall. Some small business owners, such as restaurants and entertainment, have been hard hit. These are often a key customer group for PSHPs. Many of the people that have lost their jobs during the pandemic have also lost their insurance coverage or can’t afford to continue it under COBRA. Some of these may convert to Medicaid or ACA individual coverage.

Medicaid is a special challenge for states, health plans, and providers. States have lost tax income during the pandemic, while the number of people on Medicaid has been growing. To manage their costs, states will reduce reimbursement to providers and health plans. This will make it especially challenging for health plans that are part of a health system. There is also a vulnerability in the Medicaid and dual eligible populations where COVID has hit minority populations disproportionately. The pandemic has raised the focus on social determinants of health. The demand for behavior health services has also increased as health plan members have been experiencing higher rates of depression, anxiety, and loneliness.

The pandemic has created many operational challenges for health plans and their provider networks. After years of encouraging the use of telehealth and virtual care, the use of remote technology exploded earlier this year. The redesign of provider practices to leverage the continued use of this technology and getting the reimbursement aligned will continue. This is an opportunity for PSHPs and integrated health systems to expand virtual care.

So many businesses converted to virtual workplaces during the pandemic, and provider-sponsored health plans did as well. Some had been moving toward virtual workforce opportunities in key areas like care management, IT, and customer service for a number of years, but the pandemic has accelerated this trend. Health plans will be looking at how to make technology more effective to support its workforce, customers, and providers. With a remote workforce, productivity across all employees and orienting new employees to the company can be very challenging. One PSHP CEO said their strong culture helped support their workforce challenges. Another CEO said he requires video participation for team meetings to create more of a sense of involvement and to cut down on multitasking.

Times of great change and chaos also create opportunities for innovation and change. As we work our way through the pandemic, the election results, and a stressed national and global economy, it will take new ways of doing business and finding collaborative approaches to evolve the landscape for the financing and delivery of care.

Cathy EddyProvider-sponsored health plans in the era of COVID
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WANTED: new answer to growing COB problem

As many as 15% of your health plan members have other insurance coverage, creating a multi-million dollar impact on your health plan’s time, resources, and, ultimately, bottom line. In instances of overlapping coverage, health plans shoulder the burden of accurate claim payments. The arduous process of identifying other insurance, validating coverage status, and recovering incorrectly paid claims all generate substantial administrative costs and greatly affect provider and member relationships.

There are several trends that contribute to the issue of incorrectly coordinated claims. First are continual changes in membership. Take, for example, the nation’s aging population. Increasing numbers of baby boomers are reaching age 65 and becoming eligible for Medicare. At the same time, the percentage of retirement-age Americans who continue to work has doubled since 1985, surpassing the 20% mark in February 2019. Many of these older workers are covered by both their employers’ plans and by Medicare. In addition, health plans’ current claims processing environments entail highly manual, error-prone methods for verifying eligibility and insurance information. As many as a third of claims are paid incorrectly each year, contributing to approximately $1 trillion in annual waste.

Halloween at Discovery

These trends create a need for a new, modern approach to coordination of benefits (COB). In today’s competitive marketplace, the old tried and true approach to coordination of benefits—sending lots of member surveys (that cause member abrasion) and doing routine data mining (which produces lots of false positives)—isn’t enough anymore.

Bringing COB into the 21st century, Discovery blends the right people, processes, and technology to allow our team and our clients to work smarter rather than harder, effectively integrates data sources, looks at member eligibility holistically, and determines the most successful indicators or combination of indicators of other coverage.

A.I., meet H.I.

Our “modern” approach to COB does not mean that we’ve completely automated the process. To the contrary, Discovery believes that machines (A.I.) are only part of the coordination of benefits equation. It is the human intelligence (H.I.) component of our coordination of benefits solution that makes it very effective—and really special. A.I., meet H.I.

Sure, Discovery has built custom technology that is really awesome and supports intelligent coordination of benefits workflow and accurate findings. But it is the human factor that is Discovery’s secret sauce—the irreplaceable factor that brings things like critical thinking and an awareness of member sensitivity to the equation. It is this nexus of cutting-edge technology and amazing people that modernizes our approach to COB.

The human component of our Coordination of Benefits solution is comprised of subject matter experts with extensive experience working directly for both payers and providers. This combination creates a unique perspective in not only how to identify COB value for health plans, but also how to implement and operationalize a process that will be the least intrusive for the provider community. Everyone, including our COB leadership, has actually been in the payment integrity space on the front lines (as analysts) at one time or another. We know what it takes to bring maximum value.

Intelligent platform + data sources + matching capabilities

We pair our COB human intelligence with an intelligent, custom-built platform that supports the entire COB lifecycle. Going way beyond routine data matching, our process includes intelligent matching, workflow management, and machine learning algorithms.

Discovery uses many data sources in our algorithms. There are thousands of data sources available—some of which present a high return, while others provide minimal value. Based on our experience, Discovery focuses on the more intelligent sources that historically have a high yield. Our program consists of both traditional data and nontraditional data sources, and we’re continually evaluating new sources with high potential.

Discovery uses several matching processes to ensure the most comprehensive and accurate results possible. We supplement the demographic matching points (e.g., member name, member date of birth) by identifying and updating missing or incorrect information that is preventing a correct match. For example, our process seeks to verify inconsistent address information (“123 South West Main Street” vs. “One Two Three SW Main St.”), name normalization, and partial matches when most but not all key elements match. Additionally, we review case explosion opportunities such as when a member lives in the same household as dependent-aged children.

A modern, intelligent blend for coordination of benefits success

Discovery blends our rock-star COB human intelligence with advanced technology capabilities to deliver great results for our clients. It’s a modern COB solution that we’re proud to bring to health plans across the country now and into the future.

Ron JonesWANTED: new answer to growing COB problem
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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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DRG validation strategies for success

Research into medical billing errors shows that as many as 80% of medical bills contain errors. In 2017, CMS paid $390 billion in claims, $36 billion of which were paid in error. There are several common coding and billing error types, with incorrect DRG coding being one of them. As health plans conduct clinical audits, DRG validation plays an important role in ensuring the accuracy and validity of payments.

DRG coding errors can be caused by clerical oversight or fraudulent practices. These errors can have a significant impact on payments and the health plan’s ability to maintain payment integrity. By auditing DRG coding, health plans can work to ensure that claims comply with all guidelines and that any uncovered overpayments are recovered accordingly.

The following strategies help health plans ensure their DRG validation audits are successful.

1. Analyze trends in data

When performing a DRG validation audit, data analytics plays a key role. Sophisticated data analytics technologies include predictive analytics, rules-based algorithms, and machine learning techniques. These technologies can examine hundreds of variables from multiple data sources and bring coding errors to light.

With these tools, payers can uncover trends and patterns in incorrect coding. Rather than sifting through hundreds of claims without direction, those trends and patterns highlight the most frequent coding errors and enable auditors to review only the claims that are most likely overpaid.

2. Trust coders’ professional knowledge

While data analytics can highlight trends in incorrect coding, DRG validation audits require the knowledge of a seasoned coding professional. A trained and knowledgeable staff—coupled with data analytics—can review and analyze historical claims data, medical records, and databases to quickly pinpoint errors.

To ensure proper learning, professional coders are credentialed through organizations like AHIMA that offer education, training, and certification. AHIMA helps coders gain a fundamental to advanced understanding of clinical diagnosis coding, as well as detailed insights into all types of DRG methodologies including MS-DRG, AP-DRG, APR-DRG, and Tricare DRG.

3. Get clinical validation

The expertise of a coder reaches a limit when physician documentation and clinical indicators appear to be imprecise or incomplete. Only a trained clinician—a nurse or physician—can call clinical decisions into question and get them corrected.

With clinical oversight, the health plan can be sure to conduct medically sound audits that reduce provider abrasion and ensure medically defensible recoveries. Physicians can help providers understand the medical rationale behind DRG coding inaccuracies and show providers where they may have gone wrong in their coding and documentation practices.

The combination of advanced data analytics, the knowledge and expertise of an experienced coder, and clinical oversight helps health plans achieve greater success with their DRG validation audits. Together, these strategies help health plans recover overpayments associated with coding inaccuracies—and potentially correct the practices that caused the errors in the first place.

Learn how Discovery Health Partners can help you enhance your DRG validation audits.

Clarissa McCormick, RHIT, CCSDRG validation strategies for success
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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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