Accountability in Action award winner personifies hard work and positive attitude

Justin DeMoss was pretty surprised to find out he was Discovery Health Partners’ most recent Accountability in Action award winner. When the award was announced at the company’s quarterly meeting, Justin was away on vacation.

“All of a sudden my phone is blowing up with messages that said, ‘Hey, you won’ and ‘Congratulations,’” he says.

“It was a big surprise for me because I didn’t think I’d even be a finalist. It was certainly much appreciated. It means a great deal to me.”

The Accountability in Action award recognizes Discovery employees who go above and beyond to contribute to the company’s key results by living the “what else can I do?” attitude.

“With the accountability concept, everyone feels willing to say when they need help, and as a team we hold each other accountable,” says Justin. “The idea of accountability in action gives us more of a personal responsibility to raise our hand if we need help and we work together to fix it.”

“That’s the message I continue to demonstrate to our team as well as others I’ve worked with,” according to Justin. “If we see someone who is struggling, we hold out a hand to help them. We’re accountable to that person to help them get the job done.”

Discovery’s culture of accountability

Justin started with Discovery in 2019 and leapt at the chance to work with IT and the Development team on the company’s payment integrity platform, ReThink.

“ReThink is our internal auditing engine,” he explains. “It essentially sets the data up in a view so our auditors can look at it efficiently with some case logic to whittle down members’ claims in order to deliver the best potential cases for us to pursue. It makes auditing more efficient.”

Now a Supervisor of Content Development and Data Management, Justin manages a group of senior auditors. In addition to his supervisory role, he works cross-functionally with the IT, Implementations, and COB Operations teams, along with other key stakeholders, to develop ReThink client implementations and enhancements.

“I’m kind of the COB ‘boots on the ground’ kind of person, you could say. I work closely with my senior director Ron Jones, Coordination of Benefits Senior Manager Diana Rivas, and Coordination of Benefits Supervisor Nadia Zaragoza to get things done. I work with the senior auditors to develop content, perform testing within queries and categories, and verify auditing concepts are solid so we can move work into production.”

“Last quarter, I had the opportunity to work with Irena Trajkovski, the senior technical project manager for ReThink, who nominated me for the accountability award,” Justin shares. “She recognized the dedication and hard work I had put in to get a major platform update done.”

Justin shares credits with his coworkers

Justin gives credit to his fellow Discovery employees, including Ron Jones and Nadia Zaragoza.

“Ron trusted me and gave me the opportunity to run with ideas that I believed could add value for our clients. He has been a great mentor to me since I’ve been with Discovery. And Nadia was my supervisor before I was promoted. I’m not sure anyone works harder than Nadia, and there aren’t enough words to say how much I appreciate her.”

Team exemplifies grit

“When I started the ReThink project back in December of 2019, I felt comfortable knowing I could reach out to someone and say, ‘I’m having a little trouble with this query, could you help me out?’ They were always willing to teach me—not just to do it for me, but to show me why. That’s the Discovery culture. People here are always willing to show you and teach you something new,” Justin says.

“Everyone is very willing to pitch in, stick their neck out to try to help, and then collaborate to find the best solution.”

“Our team exemplifies grit. You could definitely call us gritty. I haven’t met one person here who wasn’t willing to get their hands dirty. Whether with something they had no knowledge of and they wanted to learn, or something they’re very knowledgeable about and wanted to teach others.”

“My team is great—and is one of the best things about working at Discovery,” says Justin. “I absolutely love all the people that I work with. They make this job so much better. We had morning standups every single day at 9:30 to talk about what’s up for the day with the ReThink project. Those 9:30 morning meetings with Irena and the whole IT team were always awesome because of the people.”

Finding the best solution together

“We’re all from different backgrounds,” explains Justin, “We’re willing to sit back and listen to input and then bounce it off each other. All our senior auditors each have about a decade of experience. We’ve been doing this a long, long, long time—we know the things to look out for. What was awesome was even when I first started, this team saw value in what I brought to the table and listened to my input.”

“Being able to work on the ReThink platform and helping develop that from a user standpoint is a big accomplishment,” Justin says. “I get to open up ReThink every day and see my fingerprints on it. I get to see the things I helped develop and the impact I’ve made to drive this team forward for the foreseeable future.”

Working productively remotely

“As a healthcare technology company, Discovery manages working remotely productively and flexibly,” says Justin.

“Though I miss the ability to turn around in my cubicles and ask someone to look at something, or pass someone in the hall and have that quick 2-minute conversation, or even talk about that game last night—working remotely has allowed me to see the personal side of my coworkers who are working from home.”

Justin lives near Louisville, Kentucky, with two dogs and a cat and admits that the coronavirus lockdowns have cut into two of his favorite hobbies—golfing and travelling.

“I’m sure people laugh at me now during videoconference meetings because I got a new puppy in October, and she’s running my life. Breezy, a Great Dane pup, loves to curl up in my lap, and every once in a while when we’re having a meeting, she decides to show her face. Everybody knows her already.”

“I’ll definitely be using my extra paid day off from this award for a golf outing,” he says, laughing.

Justin DeMoss is a Supervisor of Content Development and Data Management at Discovery Health Partners. Justin started with Discovery in 2019 and brings over a decade of experience in the insurance industry to his role.

Discovery has built a culture of accountability throughout the company and created a quarterly award to recognize employees that have a stake in the company and go above and beyond by living the “what else can I do?” attitude.

Congratulations to Q3 2020 Accountability in Action award runners-up!

Sami is able to not only recover more money than before, but he is endlessly coming up with diverse, creative and efficient ways to recover more funds for our clients.
Christine Garcia, Accountability in Action award runner-up
“Edgar consistently goes above and beyond to provide valuable support for resolving system and technology-related issues. His persistence and tenacity enable him to resolve things swiftly.”

If you’d like to learn more about the steps to accountability and building this kind of culture at your organization, we recommend the book The Oz Principle.

Discovery Health PartnersAccountability in Action award winner personifies hard work and positive attitude
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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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Productivity and innovation in the healthcare industry

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.

3 out-of-the-box ideas to support your employees during the pandemic and beyond

I was recently thinking about how productivity in the healthcare industry has been impacted during this pandemic—and what healthcare leaders could do to help their employees. This extended coronavirus situation may well extend throughout 2021. This “new normal” calls for a completely different response from companies, one that recognizes what people’s lives are like now.

Parents of school-aged children make up a hefty percentage of the healthcare workforce. These employees are juggling work-from-home challenges on top of the demands of their children’s virtual learning schedules. Add to that a “pandemic fatigue” that is growing as the COVID storm continues month after month, and healthcare leaders need to consider innovative—perhaps radical—ways they can support their employers right now.

Radical idea #1: Employer support for virtual education

There are a lot of things healthcare companies can look at to help employees manage their productivity and balance their home and work life. I recently read about “learning pods” that parents are setting up to help educate their kids when they’re homeschooling and the parents are working. These virtual or in-person “learning pods,” according to a CNBC article, are small groups of students learning together with the help of a tutor or teacher.

How will leadership help stem the possible loss of women in the workforce?

Up to three-quarters of the healthcare industry’s workforce are women, many of them who are now juggling virtual learning with their other demands.

According to a Wall Street Journal article, more than one in four women indicated they may quit or scale back their jobs.

A staggering four times as many women as men have dropped out of the labor force, with many employers concerned that the coronavirus will undermine workplace equity and corporate effectiveness. This could have implications for companies’ productivity across a host of functions—and drives home the need for truly innovative and immediately beneficial solutions.

If I were an employer and had a lot of parents in my workforce, I’d be interested in exploring how this could help my employees and how I could facilitate bringing people together or even providing technology, corporate assets, scheduling flexibility, or assistance to run these pods.

How could you put these together so that your people could work more productively—and help retain staff and build loyalty?

When people feel like they’re part of a community, they’re more productive and committed to what they’re doing

People want to work for a company that cares, not only about their well-being but their children’s educational needs. This is how companies build loyalty and make people feel valued.

We now have to think about a very different kind of model, a model that recognizes where people’s lives are at right now. It has to be part of our business when you have employees dealing with a major crisis not of their making. To not try to be creative and flexible is a long-term formula for losing your best and your brightest.

I think this coronavirus is with us for another year, and in order to maintain any sort of productivity at all, we have to help these folks who are trying to balance work with virtual learning and running their households. That’s probably the biggest benefit we could ever offer working parents. You’d be embedding into your employee population that you care about children and you care about education. It’s really important right now to show that employers are willing to support parents. It’s a benefit that is incredibly timely.

Radical idea #2: Apprenticeship programs

I’ve been seeing a trend of employers offering apprenticeships, allowing workers the opportunity to develop new skill sets in another area of the company for a specific period of time. There used to be a mindset that you had to have a college degree or a Master’s degree to learn a new skill or to be qualified for developmental programs. But now employers are looking for new ways to improve productivity and provide ongoing career development to employees that also have a practical outcome.

An apprenticeship is designed for qualified, high-performing, and dedicated employees who want to learn a new skill within their company. It’s on-the-job education that exposes employees to a new discipline. Giving employees career development opportunities within their own company can be a very powerful thing. A company could also offer an online resource center for education within the company, with a “librarian” who helps with curriculum design.

Radical idea #3: Employee-driven facilities design

Hospital systems have had to figure out their onsite work situation and staffing during COVID, but health plans probably haven’t thought this through completely. A lot of the teams aren’t finding Zoom calls completely satisfactory, and some business-facing teams like sales and marketing may not be as productive as they could be. They’re not able to benefit from the energy of bouncing ideas off each other on a real-time basis. While some teams can work remotely with no productivity issues, other teams have been impacted by the work-from-home environment and could benefit from returning to working back at the office.

By surveying the groups most impacted by working remotely, you’ll get a clearer view of employees’ feelings about coming back, what they would want the office of the future to look like, and how a targeted and phased approach to working in a new onsite environment could work both for safety and productivity.

Bear in mind, overlaying all these employee considerations are health policy changes that are going to require more adaptation and change. Those changes could compel employers to accelerate a return to the office for targeted groups.

Become a company that thinks about the challenges of your people

When it comes to exploring radical solutions to help employees, true leaders are willing to say “This is worth exploring. It might be messy, and never done before, but I’m willing to try it.”

There are some incredibly inventive things you could do. What a lot of companies don’t understand is that the cost of turnover is tremendous. When an employee walks out that door, the cost to replace them is not only significant, but you’ve also lost valuable knowledge. By showing employees you care about them, and not just giving lip service to it, you create a community that is more productive and more committed.

Amanda FoxProductivity and innovation in the healthcare industry
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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 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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Discovery’s pandemic-style Halloween

This year marks my sixth Halloween at Discovery Health Partners. Why, you might ask, am I aware of how many Halloweens I’ve celebrated here? Well, first of all, Halloween is one of my favorite holidays—along with all the sights, sounds, tricks, and treats that it brings. But when I joined Discovery in 2014, I had no idea if others would share my enthusiasm—after all, I’m a grown woman, and Halloween is only for kids, right??!! Would my new company allow celebrations in the office for Halloween? Could I decorate my workspace? If I wore a costume, would I be the only one?

As it turned out and to my delight, I soon found out that the answers were yes, yes and yes! Full disclosure—I had decided NOT to dress up in a costume my first Halloween at Discovery because I thought maybe my coworkers were trying to prank me into being the only one in costume. The lesson I quickly learned is that Halloween—and celebrations of many kinds—is an integral part of Discovery’s culture and demonstrate the importance the company places on engaging its employees, encouraging cross-departmental relationship building, creating a sense of community and belonging, and celebrating its people.

Halloween is serious business at Discovery: departments compete for the best-decorated office space; we serve a potluck luncheon featuring employees’ specialty dishes; and hold a full-blown costume contest where employees go all out with their costumes, full makeup, and get in character to walk the competition runway, cheered on by teammates and colleagues.

Halloween at Discovery

A virtual twist on employee participation

Because we’ve got the Halloween spirit baked into our DNA at Discovery, not even a pandemic will stand in the way of our 2020 Discovery Halloween plans—we’ll just add a virtual twist.

For most of us, our offices are now at home. Instead of decorated cubicles and office spaces, this year we’ll share photos of our decorated home spaces, where we can offer digital ‘oohs’ and ‘ahhs’ and even get ideas for next year.

Wearing face masks have, at least for now, become part of our new normal. Our “COVID Halloween mask” contest will take the place of the in-person costume contest runway. We’ll share photos of ourselves in our best Halloween-decorated COVID masks, and the entire company will vote to select the best in several categories. The photos will be shared on a virtual runway during our quarterly company meeting, where the winners will be announced.

Because it seems that more than a few of us at Discovery enjoy a little friendly competition, on the day before Halloween, we’ll share our lunchtime and knowledge of all things Halloween during own Discovery Halloween Virtual Trivia contest. Winners’ bragging rights are at stake—and believe me, we take those seriously, too!

Our family members and pets are often also our officemates right now. So we’ll include them in our plans by sharing photos of them, and ourselves, celebrating Halloween and other fall traditions—pumpkin carving, apple picking, dressing in costumes. Since we can’t be physically together to share our potluck, we’ll share photos and recipes of our favorite Halloween and fall specialties and treats.

And, in keeping with our #2020Good campaign, we’ll share our time, talent, or treasures with others in need and hope to inspire others to do the same.

Growing up, many of us have experienced Halloweens that were so cold that trick-or-treaters were forced to hide their costumes under bulky winter coats. There were also lots of rainy Halloweens that soaked kids to the bone. But we figured it out then and still carried on. And we’ll figure it again this year despite the limitations that COVID brings. With Discovery’s commitment to engaging its employees and celebrating its people, we’re sure that Halloween 2020 will be another one for the Discovery history books!

Jan GedminasDiscovery’s pandemic-style Halloween
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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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Award-winning Irena Trajkovski’s superpower is her team

Irena Trajkovski, Senior Technical Project Manager at Discovery, is a winner of this quarter’s Accountability in Action award. For Irena and many in IT, sitting in front of a computer screen all day can make it difficult to see the big picture and understand how their work helps the company achieve its goals. That all changed when Discovery implemented its accountability program. Irena said, “It makes my work more meaningful. It’s motivating to know that what I do as a project manager contributes to Discovery’s larger goals.”

Beginning in 2019, Discovery built a culture of accountability that helps employees think and act in new ways to achieve key company results. The program is founded on four best practices of accountability:

  • Identifying gaps in execution
  • Personally owning responsibilities and aligning them to the company’s key results
  • Creatively and collaboratively working on solutions
  • Actively executing on solutions while building an environment of trust

Irena embodies these traits in her work. In March 2020, Irena led a special project to convert COB client data from an existing platform to the company’s new ReThink tool. The new data analytics platform gives claims auditors the tools they need to work more efficiently and more easily identify recovery opportunities for clients. Crucial to the success of the program was migrating data to the new platform and ensuring its accuracy without interrupting auditors’ work.

The accountability program played a key role in the success of the project.

“The accountability program changed the perspective of project management,” said Irena. “It empowers everyone, regardless of their role, to know that they can make an impact. If they see something, they can take the initiative to do something.”

The program helps employees identify whether their behavior is “above the line” or “below the line,” Irena explained. “We can call out ‘below the line’ behavior, encouraging others and examining what we can do personally to stop complaining about circumstances and, instead, go the extra mile. That has been very impactful for me as a project manager and for the whole team.”

One example of this happened when Irena and her team lacked quality assurance resources to test their work. Rather than letting it stop them, the team asked themselves what they could do about it. They identified someone on the team who had a similar skill set and took the initiative to fill that role.

When asked about the impact of the program, Irena said, “It has really provided a breath of fresh air for our company and inspires and empowers people to feel like they can make a difference. It connects our work to the company’s mission and goals.”

Irena credits her team for her success with the accountability program. “My superpower is my team,” she said. “I work with a team of talented individuals. When they are doing their best, it motivates me to do my best.”

When she’s not busy at work, Irena is busy at home with two toddlers, ages two and three. She enjoys going on nature walks with her husband and kids, doing daily yoga or Pilates, and trying new recipes in the kitchen.

If you’d like to learn more about the steps to accountability and building this kind of culture at your organization, we recommend the book The Oz Principle.

Discovery Health PartnersAward-winning Irena Trajkovski’s superpower is her team
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