The evolving leadership role in healthcare

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.


We’re all well aware of the many challenges facing our industry and our country right now. A perfect storm of a pandemic, political turmoil, economic stress, and current events have people feeling under siege. Add to that a healthcare industry that is continually under fire and buffeted by changes. Sheltering in place, working remotely while balancing both family and work commitments, and an extremely polarized country have created some truly stressful times.

But out of this chaos comes an opportunity to rethink how we in the healthcare industry do business. It’s an opportunity to create an inclusive corporate culture where people feel they’re doing something important. It’s also the perfect time to rethink how we bring people into the workforce who can work well remotely and independently, yet still add to the sense of community we want to maintain.

The impact on the workforce

I personally know many people who are feeling disconnected, stressed, and overwhelmed right now. It’s the job of the leadership team to make people feel good about where they are and confident that the company can navigate through the chaos. That’s a pretty challenging assignment for leadership!

Leading in the new normal

Evolving leadership in the healthcare industry is more than just being reactive. This could be the moment for companies to get it right, to turn the box upside down and try to put the puzzle back together in a different way. An opportunity for companies to become compelling places for people to work and add value. Recognizing that something like the coronavirus could happen again—how do we prepare for it in the future? The legacy of COVID isn’t going away in a month or two—we could be looking at a year or two.

We need to rethink our formula for success both short- and long-term.

Some things leadership needs to consider

  • How do we need to change talent recruitment and development to prepare for the future?
  • How do we recruit people who can work well remotely and independently, but who still want to be part of a group?
  • Are we spending our money on our employees in the right places?
  • What’s the profile of someone who can adjust to this new environment and thrive in it?
  • How do our systems support adaptability and flexibility of individuals?
  • How do we create a pipeline of diversity and make inclusion part of the corporate culture?

We need a plan B

Healthcare companies are beginning to grapple with the issue of how to create a sense of community and identification in a fragmented world. And that’s going to take some thought in terms of what is it that people treasure, what is it that they really value, and what is it about your company that they identify with. And if there isn’t anything they identify with, why not?

Corporate cultures have typically tended to minimize creativity and innovation individually and in teams. Going forward, I think the only way corporate cultures are going to survive is if they are committed to having the best ideas and developing new responses.

To understand the answers to these questions, we must listen to what our employees say. The new model has to give employees the tools they need and recognize their capacity for individual thinking and creativity.

Leadership needs to rethink what you need to accomplish as an organization—5 years or longer. Rather than look at efficiency—the most results with the fewest people—you will have to think about how to improve community productivity.

For example, in the past, you would have had people come to a meeting and work on a project together. You assumed everyone knew each other. But in this world, you will have to make a real effort to help them.

It’s the perfect opportunity for companies to reinvent how they get work done.

My personal trainer was forced to rethink his company because no one wanted to go to the gym. He now makes most of his money doing virtual training. He has scheduled a lot more people because now he doesn’t have to go back and forth to clients. He’s making more money than before.

He rethought how he did the work—which is what’s needed in companies large and small across the country.

We may be looking at several years of change. It’s no doubt a chaotic environment—but it could be a creative one if we rigorously review what works and what doesn’t and rapidly eliminate the latter.


Two books I recommend: Leadership in Turbulent Times by Doris Kearns Goodwin and The Splendid and the Vile by Erik Larson.


Get inspired by leaders who led through difficult times

True leaders offer people a sense of security and a sense of focus. They serve as a beacon for people. In The Splendid and the Vile by Erik Larson, you see how Churchill allowed the British people to feel that they would get through this, that they were moving forward. He never lost courage and his courage bolstered the entire nation.

Another great read, Leadership in Turbulent Times by Doris Kearns Goodwin takes a look at four inspirational presidents who steered our country during chaotic and turbulent times. Lincoln had to deal with a civil war and social injustice that threatened to destroy a nation not yet 100 years old.

Both Churchill and Lincoln shared a quality of exceptional leaders—that sense of identification and connectedness with their people. Both of these leaders stayed close to their people. They also provided their people with a clear vision of the future as well as a realistic vision of failure.

People don’t look to leaders for specific answers, but they do expect and value integrity, principles, commitment, and courage. A frazzled employee who is balancing work and home schooling wants to know the person leading the company appreciates them and will be flexible enough to allow them to solve problems without unnecessary restrictions.

Amanda FoxThe evolving leadership role in healthcare
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Even a pandemic can’t stop the hackers

Despite being in the middle of a pandemic, hackers have wasted no time in stealing patient and personal data. Here is a summary of cybersecurity breaches that occurred over the year to several healthcare entities:

Florida Orthopaedic Institute (FOI): a ransomware attack inserted malware on their servers. Administrators were able to quickly secure the system, but the investigation found that patient data was potentially exfiltrated or accessed during the attack. 640,000 patients were impacted.

Magellan Health: a sophisticated ransomware attack hit their servers, compromising the data of 365,000 patients. Hackers gained access by leveraging a social engineering phishing scheme that impersonated a Magellan Health client five days before the ransomware was deployed.

BJC Healthcare (Missouri): a phishing attack was detected by its security team on the same day it occurred, however the data was still compromised, impacting about 288,000 patients.

Benefit Recovery Specialists (Missouri): employee credentials were hacked to gain access to the insurer’s systems and deploy malware, breaching the data of 274,837 patients from several providers and payers that use them for billing and collections services.

Ambry Genetics (California): This clinical genomic diagnostics vendor suffered an email hack which compromised the data of 232,772 patients. The hacker gained access through an employee’s email.

Northwestern Memorial Healthcare: 56,000 donors and patients were notified that their personal records were accessed due to a data breach by one of their software vendors (Blackbaud) where an unauthorized party had gained access to Blackbaud’s systems.

Northshore Health System: 348,000 patients, employees, and/or donors were notified that their personal records were accessed due to a data breach by one of their software vendors (Blackbaud), where an unauthorized party had gained access to Blackbaud’s systems.

University of Kentucky Healthcare: 163,000 patients, employees, and/or donors were notified that their personal records were accessed due to a data breach by one of their software vendors (Blackbaud), where an unauthorized party had gained access to Blackbaud’s systems.

Roper St Francis Healthcare (South Carolina): 92,963 donors were notified that their personal records were accessed due to a data breach by one of their software vendors (Blackbaud), where an unauthorized party had gained access to Blackbaud’s systems.

Not all breaches are related to cybersecurity, but implementing cyber secure practices are still critically important. For example, the following data breaches occurred this year:

Health Share of Oregon: The theft of a laptop owned by their transportation vendor compromised the data of 654,000 patients.

Elite Emergency Physicians and St. Joseph Health System (Indiana) reported a security incident involving the improper disposal of patient records, impacting 550,000 patients through their third-party record storage vendor.

There was also an increase in phishing campaigns related to the coronavirus. For example, emails that looked like they were from the Center for Disease Control (CDC) were actually hackers trying to access data by luring the receiver into clicking the malicious link.​​​​​​​

Some may even look like they are coming from your employer, creating a sense of urgency to click on a link.

As you can see, breaches can occur in various ways, including accidental exposure by employees. Here is what Discovery is doing to remain cyber secure:

  • Making sure remote connections are secure
  • Training employees on what social engineering, phishing, and ransomware attacks look like and how to prevent employees from clicking on malicious links. Monthly training is required as part of Discovery’s ongoing commitment to security
  • Updating our vendor management process to prevent third-party incidents and breaches
  • Annual attestation to policies to help remind and educate Discovery’s workforce of our compliance, security, and privacy practices

Quick tips for recognizing and avoiding coronavirus-themed phishing emails

  • Beware of online requests for personal information. A coronavirus-themed email that seeks personal information like your Social Security number or login information is a phishing scam. Legitimate government agencies won’t ask for that information. Never respond to the email with your personal data.
  • Check the email address or link. You can inspect a link by hovering your mouse button over the URL to see where it leads. Sometimes, it’s obvious the web address is not legitimate. But keep in mind phishers can create links that closely resemble legitimate addresses. Notify/forward the email to your security team and delete the email.
  • Watch for spelling and grammatical mistakes. If an email includes spelling, punctuation, and grammar errors, it’s likely a sign you’ve received a phishing email.
  • Look for generic greetings. Phishing emails are unlikely to use your name. Greetings like “Dear sir or madam” can be a signal that the email is not legitimate.
  • Avoid emails that insist you act now. Phishing emails often try to create a sense of urgency or demand immediate action. The goal is to get you to click on a link and provide personal information—right now.
Asra AliEven a pandemic can’t stop the hackers
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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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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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Six ways to help your remote workforce thrive

In the pre-coronavirus world, companies moving to a remote workforce could take months to develop and implement their plans. But the sudden onset of COVID-19 gave companies very little lead time to figure out how to set up and support employees to work from home. With no time for formal training, many organizations have been left wondering how they would help their employees stay motivated and productive in this new way of working. 

Discovery moved to a remote workforce model over a year ago and has gained a wealth of work-from-home expertise. Hoping to help other organizations thrive in this new remote world, we’re sharing some best practices based on what we learned.

1. Culture eats strategy for breakfast

Often attributed to management guru Peter Drucker, this adage reminds us that a company’s culture is often the glue that binds employees together and drives the desired behaviors throughout an organization. This holds true—and perhaps becomes even more important—when the “office” is virtual. Leveraging your organization’s culture will help employees feel more connected to each other and to the company. And it’ll create a virtuous cycle—the more you reinforce your culture, the stronger it’ll get. Is cross-functional team collaboration an important part of your culture? Use regular recurring meetings and communications—weekly emails from the CEO, monthly company meetings—to showcase how your teams are working collaboratively. 

2. Effective managers manage, wherever their employees are

Whether employees are in a physical office or working from home offices, effective managers are the ones who use the right combination of motivation, monitoring, and feedback to keep their teams productive and engaged. When faced with the need to manage their teams remotely, some managers may require more support than others. It can’t be overstated how important it is to invest in helping managers be effective—the ROI is huge. Tap into your highly-effective managers as resources to help build up other managers’ skills. Conduct regular meetings and trainings to reinforce best practices and develop management skills. When the pandemic hit, Discovery pivoted from monthly people manager meetings to weekly check-ins. This allows people managers to problem-solve the new COVID-19-related challenges their teams may be experiencing.

3. Make your expectations clear and water what you want to grow

Pandemic or no pandemic, a key to a company’s ability to reach its goals has always been setting clear expectations and ensuring that all employees understand those expectations. Clear expectations act as a connecting force throughout your team and organization, creating alignment so everyone is working together to make the right things happen. At Discovery, we’ve defined our expectations through our five Core Values—Trusted Quality, Reliable Results, Applied Innovation, Mindful Stewardship, and Profound Client Value. These values guide every single employee’s decisions and actions. 

Being clear with expectations must be coupled with holding ourselves and others accountable. Team and company leads need to proactively manage their processes in order to get the results they expect. Water what you want to grow—reinforce accountability, reward positive behaviors, celebrate employees who demonstrate their commitment to goals. When employees are remote, it’s critically important to do these things in a way that others can “see.” Discovery uses an online “Impressions” portal for giving and receiving kudos to employees who demonstrate behaviors consistent with our expectations. Everyone in the company can see who’s living our Core Values.

4. Trust…and verify

If you’ve clearly set expectations and are holding people accountable, then you’re well on your way to mastering this best practice. Being remote requires a good deal of trust that employees are managing their time effectively and concentrating on the right things. But you must also check in and check up. Make it a priority to connect with team members on a regular basis so they know you want to stay connected to what they’re working on. This also gives you an opportunity to ensure every team member has what they need to do their job effectively. Use a combination of instant messaging, video conferencing, email, phone, texts, or whatever works best for you and your team to be available and responsive when questions come up. Remember to also check in with employees frequently just to ask how it’s going.

5. Flexibility is free productivity…and free employee engagement

Flexibility is the secret sauce for helping remote employees stay productive. Nearly everyone’s daily life has been disrupted by social distancing, work furloughs, school closings, and other changes. Managers can help remote employees stay on task by working with them to establish schedules, processes, and timelines that balance individual needs with those of your team. Even a small accommodation like moving a meeting by 15 minutes can make a big difference. And remember, life at home still goes on even while employees are working. Learn to embrace those everyday interruptions!

6. Above all else, stay connected and communicate, communicate, communicate

Make sure your teams know what’s going on and have the information they need to do their jobs. People crave personal interaction, and working remotely can cause feelings of isolation and being cut off socially from coworkers. Carve out time during the day for your employees to connect with others. Take virtual coffee breaks or meet-up by video conference to brainstorm ideas, problem-solve, or just talk. You can even plan a virtual happy hour, virtual escape room, or other team events. It doesn’t have to be formal; be sure to lean on your employees for ideas. An unexpected benefit of working virtually is that co-workers are often more open and relaxed outside the office environment. Use this to your advantage and get to know each other on whole new level! 

COVID-19 has presented some unique challenges for organizations suddenly transforming to a remote workforce, and it may take some trial and error to find the right approaches to managing in this new environment. By focusing on the things that are important at all times—culture, effective management, clear expectations, flexibility, and communication—you and your remote workforce can indeed thrive!

Please stay safe and remember we’re all in this together! 

 

Share your work-from-home management tips with us on LinkedIn and Twitter.

Learn more about our response to COVID-19.

Philip GarrisonSix ways to help your remote workforce thrive
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Protecting payment integrity through client-centered support

Unexpected events like the COVID-19 pandemic make it increasingly difficult for health plans to manage costs and ensure payment integrity. We recently sat down with Monica Frederick, Vice President, Account Management for Discovery Health Partners, to discuss how Discovery’s people and account management approach contribute to our clients’ success.

You’re a newer member of the Discovery Account Management Team. Can you share your experience prior to Discovery?

Over the past 20 years, I’ve held numerous sales and business development positions to support healthcare organizations in bringing new patient care modalities to the market. My experience on the medical side gives me insight into how managed care organizations can strengthen their payment integrity efforts so they can better manage costs and continue to focus on member care.

What makes Discovery a successful team and what are we doing differently to support our clients’ success?

Discovery has built a solid reputation for providing value to health plans by helping to solve their payment integrity challenges. We owe our success to our exceptional people and culture of accountability. Every employee across the organization understands the importance of their role and how they contribute to our clients’ success. And I see the whole organization working tirelessly to anticipate customers’ needs and earn their trust.

Communication is a big part of our approach to account management at Discovery. We talk to clients frequently in person and virtually, and we also conduct client surveys to hear directly from our clients on how we’re doing and how we can continue to provide profound value to our clients’ organizations.

Through this hands-on approach, we’ve learned that we do many things right. Clients especially appreciate how we advise them to determine the best course of action for their operations and provide timely follow-up to address their concerns. This valuable feedback also helps us identify opportunities where we can improve our processes and solutions to better meet clients’ needs.

In addition, we have a Client Council that brings together individuals across our client base whose voices influence the future of our business. We host in-person and virtual meetings with our Client Council to deepen relationships and understand what clients need to be successful. These meetings not only provide clients with valuable networking opportunities, but also offers clients opportunities to share insights and best practices with other health plan leaders and drive future innovations.

What is Discovery’s approach to account management, and how do we drive value throughout the entire engagement with a client?

Our approach is flexible to meet each client’s unique needs, but it always starts with earning their trust, by getting to know them and understanding their business operations. We listen closely to their concerns and create a plan that addresses their challenges and aligns with their strategy and priorities.

When clients join Discovery, we put together an implementation team with the right skills and specific expertise to ensure a smooth, accurate, and efficient implementation. Our approach is flexible and can wrap around or come behind existing vendors and processes already in place. Discovery’s multi-disciplinary teams work collaboratively and our experts evaluate each client individually. There is no one-size-fits-all approach.

Once implementation is completed, an internal hand-off to the Account Management team occurs and all unique attributes and needs for each client are discussed in detail. A dedicated account manager takes the lead to provide guidance and manage day-to-day activities and communicate the status of ongoing projects every step of the way. We don’t just hand over reports; we take time to meet regularly with clients to review their information in a way that’s meaningful so we can make recommendations for improvements and achieve their desired results.

What are some of the ways Discovery helps health plans address unexpected payment integrity challenges like the COVID-19 pandemic?

COVID-19 is unlike any event the healthcare industry has seen in modern times, thus health plans are faced with challenges they could not have imagined just a few months ago. Not only do health plans need to ensure their members receive the care they need and support their providers, health plans must also keep up with individual states’ mandates regarding “non-essential” claims processes and review of COVID-19 related claims. At the same time, they are struggling with reallocating resources to support critical COVID-19 initiatives while managing the shift to a remote workforce.

Discovery is proactively reaching out to clients to make recommendations, based on their business, to help protect premium revenue, pick up productivity shortfalls as needed, and help them protect their workforce. We continue to work diligently on behalf of clients as an extension of their teams to ensure they get the right information to support the continuity of their operations.

Discovery went remote with payment integrity operations over a year ago, so we’re in a great position to help support our clients business during the pandemic. Discovery views challenges as an opportunity to learn from individual clients’ needs. As COVID-19 plays out, we will continue to partner with clients to make sure we are supporting them and their challenges are addressed in a timely manner.

 

Find out how Discovery Health Partners can help contribute to your payment integrity success in 2020. Contact us today!

Monica FrederickProtecting payment integrity through client-centered support
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How COVID-19 trends are impacting payment integrity

At the close of 2019, healthcare predictions echoed the challenges of years past: complex billing processes, changing regulations, and rising healthcare costs. It was no surprise that health plans would continue to tackle these long-standing issues that contribute to improper claims payments in 2020. Little did we know, though, that payers would find themselves facing these challenges in very unexpected ways amid a global pandemic.

Health plans, bracing for the full impact of COVID-19, will need to find ways to navigate the uncharted course―a course that is no longer focused primarily on cost efficiency, quality, and delivery standards. Rather, a new course is taking shape that centers on safety, performance, and demand.

Promoting safety and well-being

In response to the COVID-19 pandemic, most states have issued shelter-in-place orders, requiring non-essential businesses and staff to work from home. Health plans are now faced with either remaining open as a critical operation or moving operations to newly established remote environments. For some plans, the transition from offices to mandatory work-from-home settings can present initial challenges (e.g., operational requirements, data security). As these challenges are addressed, payers are also working with their provider partners to increase access to care while protecting providers and the community. For example, the expansion of remote care and monitoring services help support social distancing and reduce the risk of exposure to COVID-19.

Facing financial performance impacts

The total number of COVID-19 cases continues to rise, prompting healthcare associations to recommend the suspension of elective surgeries and procedures to maintain sufficient capacity to treat patients and minimize risks of exposure. As those types of claims decrease, we anticipate a spike of high-dollar inpatient claims to treat individuals affected by COVID-19. In fact, a recent analysis by S&P Global estimates a severe COVID-19 pandemic could cost U.S. health plans more than $90 billion in medical claims alone1. While several major health plans have recently pledged to waive costs associated with COVID-19 treatment, we can expect these costs will cause health plans to experience significant financial stress.

To offset these great costs, we recommend health plans with large Medicare populations to look to other areas to positively impact revenue. For example, Premium Restoration (the recovery and protection of premium revenue) is one way to maximize financial performance in 2020 while not disrupting COVID-19 initiatives.

Increasing demands on healthcare organizations

It’s no surprise that as COVID-19 cases continue to grow, so are claims for testing and treatment and, more importantly, high-dollar inpatient stays. To this end, the Centers for Medicare & Medicaid Services (CMS) has issued new guidelines that lift restrictions and offer more flexible coverage options (e.g., tele-health). The American Medical Association (AMA) has also provided special coding advice to help healthcare professionals during the COVID-19 public health emergency. And in an effort to help ease the strain the pandemic is creating for healthcare providers, health plans are suspending reviews on COVID-19 related claims

With so many rapidly changing policies and requests, the regulatory burden is mounting for both health plans and providers alike. It will be more important than ever to make sure your plan has the correct member eligibility to avoid months of catch-up. Given these uncertain times, we highly recommend plans have a strong coordination of benefits (COB) program in place to ensure accurate and updated eligibility data while driving future cost avoidance.

Contact Discovery Health Partners today to find out how we can help you with your payment integrity efforts amid COVID-19.

Access the latest COVID-19 information from our COVID-19 response page.

Discovery Health PartnersHow COVID-19 trends are impacting payment integrity
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Jason Brown on the road ahead for payment integrity

As the industry transitions from volume to value-based healthcare, health plans face increasing pressure to better manage costs and ensure payment integrity. We recently sat down with Jason Brown, CEO of Discovery Health Partners, to get his thoughts on recent trends and how they’re shaping the road ahead in 2020.

Healthcare continues to change and evolve. What do you see as some of the trends setting the stage for optimizing payment integrity?

Health plans face a number of challenges when it comes to ensuring the right care is provided to the right member for the right amount. Complex billing processes, changing regulations, outdated and disparate data systems, and overlapping coverage all contribute to improperly paid claims. Today, nearly a third of claims are paid incorrectly, leading to billions in administrative waste.

In 2020 and beyond, we anticipate health plans will continue to struggle with rising healthcare costs, numerous competing priorities, and a lack of resources. Furthermore, changing regulations and mandates will continue to add layers of administrative and clinical complexity to a system already bogged down in paperwork. While there is no clear path to cost containment, there are ways health plans can work toward transforming their payment integrity approaches. An example is leveraging advanced technologies to move from retrospective payment to prospective payment—by detecting improper claims before they are paid, health plans can keep costs in check, increase member satisfaction, and most importantly, cultivate healthy provider partnerships.

What are some of the ways Discovery is helping health plans address their payment integrity challenges?

This past year has been an exciting time of innovation and growth for Discovery. We have an expanded suite of payment integrity solutions—Coordination of Benefits, Subrogation, Data Mining, Clinical Audits (in areas such as diagnosis-related group (DRG) audits and itemized bill review audits) and Premium Restoration. Our integrated solutions are designed to work together. This connected approach helps optimize claims recoveries and avoid future expenses across the entire claim lifecycle while reducing provider and member abrasion.

What makes Discovery unique is that our solutions start with our clients’ own data and processes. We leverage the latest analytical tools and technology like machine learning to identify patterns that present opportunities for cost recovery and cost savings. By blending artificial intelligence with human expertise, we identify hidden errors and root causes that are often overlooked. We also provide the highest levels of support to our clients, acting as an extension of their teams, to free up their internal resources so they can focus on other business priorities.

Since its inception, Discovery has been proud to provide flexible solutions that help health plans solve their payment integrity challenges. Our newly formed Client Council provides a platform for clients to share industry insights and challenges with their peers and help drive product innovations with Discovery. Going forward, custom-tailored solutions like ours will be key to helping plans manage costs while maintaining the high levels of care that their members expect.

What’s on the horizon for Discovery in 2020?

During the past decade, we’ve demonstrated measurable success by helping our clients improve operational efficiencies, increase claims accuracy and payment, and recover dollars back to their health plans.

From 2020 forward, we will continue to evolve existing solutions and create new forward-thinking approaches to help plans prevent and recover inaccurate payments. By expanding our use of data analytics and data integration and accelerating our investments in research and technology like machine learning and predictive analytics, we will help health plans capitalize on information to coordinate claims correctly. Once individual plans reach the point where they are paying the appropriate amount for the healthcare that’s delivered, they can re-invest in clinical care for their members.

At the same time, we will position clients to transition toward a more proactive approach to cost management. Reimagining the payments process and applying insights further upstream will be key to enabling providers to take advantage of opportunities to proactively change wasteful behaviors.

And of course, we’ll continue to keep our finger on the pulse of the industry. By building partnerships with our clients, industry organizations, agencies and others to learn about best practices and stay on top of the latest trends, we can prepare clients for the challenges ahead.

 

Find out how Discovery Health Partners can help strengthen your payment integrity initiatives in 2020. Contact us today!

Jason BrownJason Brown on the road ahead for payment integrity
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