Award winner Christine Garcia knows accountability isn’t a solo act

One way that Discovery delivers on its core values of reliable results, trusted quality, and profound client value is by building a culture of accountability. Discovery has invested in a comprehensive accountability model based on the concept that when people take personal ownership of the company’s goals and accept responsibility for their own performance, they work at a higher level to ensure their own success and the company’s overall success. Each quarter, Discovery’s Accountability in Action award recognizes Discovery employees who demonstrate they have a stake in the company and who go above and beyond to contribute to the company’s key results by living the “what else can I do?” attitude.

This quarter’s Accountability in Action award recipient is Christine Garcia, Senior Director of Shared Services and Quality Management at Discovery. Christine received the award for implementing improvements that positively impact all four of Discovery’s Key Results for 2020. In her seven years with Discovery—starting as a legal assistant and working her way up through a variety of positions and departments—Christine has gained extensive knowledge of Discovery’s day-to-day processes. She has seen first-hand how each individual and team can impact clients. When Christine took over as head of Shared Services, she drew on that experience and immediately set to work to identify opportunities for improvements, including process efficiencies and incoming mail handling processes that better meet client expectations. She also invested time in employee communication and development, providing continuous support and promoting talented supervisors and team leads, whom she credits for helping her earn this award.

“I’m very honored to receive the Accountability in Action award, but I know it wasn’t a solo effort. The collaboration and teamwork of many talented people in the company helped get me here,” she says.

Christine also credits the company’s Accountability in Action program itself as a big part of her success. She notes that since the accountability program began, she has seen a significant shift away from emphasizing individuals’ roles and contributions and, instead, toward a more collaborative mindset. By tying accountability to key enterprise metrics, the program has made individuals more aware of their everyday impact.

“Accountability is everyone’s responsibility, and the program has actually made my job easier because everyone is in lockstep now and looking at everything they do with an eye on accountability. Discovery has done a great job of supporting this program and continuing to build a culture that challenges everyone to consider if what they are doing is truly contributing to our goals. This focus helps to evaluate improvements and implement ones that create a more positive impact,” Christine explains.

For Christine, having oversight of the call center, settlement and recovery processes, user acceptance testing for program enhancements, and quality auditing programs has helped her gain a more a holistic view of how individuals and team actions impact the entire organization. It has also created more transparency and enabled Christine to position herself as a go-to resource for many other departments. “The program encourages others to reach outside their given roles and share their skills and ideas when they see an opportunity,” she says.

Christine is currently a student in the Loyola School of Law Weekend Executive program, and she plans to use her Accountability in Action cash award and extra day off with pay toward her education. True to her views on personal accountability, says she will use her law degree to continue fighting healthcare waste, fraud, and abuse at Discovery. When she’s not studying, she enjoys creative outlets including music and art and spending time with her two cats and one golden retriever.

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 winner Christine Garcia knows accountability isn’t a solo act
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How the ESRD process works. And why it sometimes doesn’t.

Medicare Advantage plans don’t typically have a large population of members with End-Stage Renal Disease (ESRD). In our work with dozens of plans, we see about 5% of members with ESRD, a condition where there is permanent and almost complete loss of kidney function.

These few members, however, can have a big impact on a plan’s financial health if the Centers for Medicare and Medicaid (CMS) are underpaying premiums for these members. And especially if CMS has been underpaying for a length of time.

The average cost to treat a patient with ESRD can run well over $60,000 a year because members may require dialysis several times a week. To offset this higher cost of care, CMS typically pays health plans a premium of $7,100 for managing members with ESRD, compared to a premium of $815 for non-ESRD members. When you multiply the gap between non-ESRD premiums and ESRD premiums year over year, having the wrong ESRD status for a member can be quite costly to your plan.

Hear from the experts

Discovery ESRD Premium Specialist Janayth Carmona sits down with colleagues and ESRD Premium Restoration experts Alex Projansky and Denise Ytsen to discuss their experience working with inaccuracies in members’ ESRD statuses—and why it can be so costly to your health plan.

Ongoing inaccuracies can mean that your plan is losing out on millions of dollars

Determining the cause of the error is time-consuming—and can be complicated—for health plans.

When you multiply the gap between non-ESRD premiums and ESRD premiums year over year, having the wrong status for your ESRD members can cost your plan millions.

Let’s take a look at how the ESRD process ideally works:

  1. The ESRD patient visits a dialysis clinic for treatment.
  2. The dialysis clinic or submitting authority fills out form 2728 (completely and accurately) and submits this to CMS through CROWNWeb, the data-management system that allows Medicare-certified dialysis facilities to safely submit facility and patient data to CMS.
  3. CMS is alerted to the patient’s ESRD status—and an ESRD indicator flag is turned on that will adjust the premium for that patient.
  4. Your plan then receives a higher premium for covering these patients.

In some situations, however, the process breaks down:

  • Members have ESRD diagnoses that your plan never knew about
  • The dialysis clinic or provider doesn’t complete the 2728 form or sends incomplete or incorrect forms
  • The clinic saves the form in CROWNWeb but doesn’t hit “submit”
  • Flag are temporarily turned off and not turned back on—for example, because the member went to hospice for a period of time
  • CMS fails to set the flag or had inaccurate dialysis start dates

Discovery is adept at navigating these complex processes and restoring premiums

Discovery can help your plan identify members with missing ESRD statuses and work to correct the errors at the source—by working directly with the submitting provider and CMS.

To begin our restoration process, we use the plan’s historical claims data and multiple data sources to identify claims diagnosis patterns. We look at the detailed membership files to see if that ESRD flag is present. If it’s not, we reach out directly to the dialysis center and, if needed, get the 2728 form resubmitted properly.

This can sometimes prove challenging as the dialysis center’s main focus is on patient care and not necessarily on ensuring the 2728 form has been completed accurately and submitted through CROWNWeb appropriately. So, our team will explain the importance of following CMS guidelines and will work with the dialysis center from start to finish to ensure the form is accurately re-submitted through CROWNWeb. We also coordinate with CMS to make sure that flag gets turned for the appropriate timeframe. Finally, we track the CMS Monthly Membership Report (MMR) updates and continuously monitor MMRs to ensure the flags remain on, as necessary.

Let us start reviewing your records

Discovery Health Partners can help find value for any size health plan, utilizing an 84-month non-intrusive lookback that restores actual premium dollars based on corrected ESRD flags. Plus, based on corrected ESRD flags, our lookback work ensures that future premiums are paid accurately for members with ESRD.

Learn more about Discovery’s ESRD Premium Restoration solution.

Alex ProjanskyHow the ESRD process works. And why it sometimes doesn’t.
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End-Stage Renal Disease (ESRD) FAQs

We recently talked about the need for Medicare Advantage plans to ensure that premium dollars coming in from the Centers for Medicare and Medicaid Services (CMS) are accurate. As with Medicare Secondary Payer, Medicare Advantage plans are losing out on premium dollars from members with End-Stage Renal Disease (ESRD).

Members with End-Stage Renal Disease account for a disproportionate amount of medical expenses. Experience shows that health plans are underpaid an average of $50,000 in CMS premiums for each misidentified or inappropriately documented ESRD member. Correcting inaccuracies and ensuring accurate submissions to CMS help plans restore millions in underpaid premium dollars. Here are answers to a few frequently asked questions about End-Stage Renal Disease validation:

What is End-Stage Renal Disease (ESRD)?

End-Stage Renal Disease, also known as ESRD, is a condition in which there is permanent and almost complete loss of kidney function. Some of these patients are treated by dialysis or kidney transplant. If members are flagged appropriately with the Centers for Medicare and Medicaid Services (CMS), the Medicare Advantage plan will receive the appropriate premium amount to pay for their care.

The challenge with ESRD members is that it is up to dialysis providers to submit appropriate documentation to CMS for members with ESRD. The plan has no control over this. Dialysis clinics can be difficult to work with due to high turnover and a lack of motivation to ensure accuracy.

What is the financial impact of ESRD to Medicare Advantage plans?

Medicare Advantage plans pay the full cost of ESRD claims, regardless of the amount of premium dollars received from CMS. For the sake of comparison, the average Medicare Advantage premium is $815. The average ESRD premium is $7,100. Multiply the difference over multiple members and multiple months, and the financial impact becomes significant.

What are common reasons that ESRD status is missed?

There are three areas where ESRD status is missed and where recovery opportunities exist. First, there may be members with ESRD diagnoses that the plan never knew about. Second, the member may have been flagged with ESRD at one point in time, but the flag was turned off and never turned back on. This may happen in a scenario in which the member went to hospice for a period of time. Lastly, the ESRD dates might not line up. CMS may not have paid the ESRD premium for the first few months of dialysis treatment.

What does ESRD validation entail?

When looking to ensure accurate premiums for ESRD members, the plan needs to first verify where it might recoup premiums due to missing ESRD flags. Once those members have been identified, the plan will want to ensure the complete and accurate submission of required documentation to CMS. Plans can recoup ESRD premiums for the previous 84 months.

Some Medicare Advantage plans find that they lack the resources to focus on ESRD validation or lack continuity due to multiple points of ownership throughout the organization. And the process of identifying members, gathering and correcting documentation, and working with dialysis clinics can be time-consuming and overwhelming. In these cases, the plan is wise to work with an ESRD validation vendor.

What do I need to consider when partnering with an ESRD validation vendor?

There are several factors to consider when evaluating ESRD validation partners. Most important is making sure the vendor has experience in the process and has developed proven best practices with measurable results.

Analytics plays a key role. The ideal partner will have developed advanced analytics and strong proprietary algorithms to find eligible members. Also important are established relationships with dialysis centers across the country and best practices developed with CMS over time.

In addition, the partner will manage the entire process from start to finish, requiring minimal to no involvement from the plan. The vendor will use proprietary analytics to identify members with the highest propensity of inaccurate ESRD statuses, perform subject matter expert review, work with dialysis clinics to correct data inaccuracies, submit accurate reports to CMS, and monitor the submission and acceptance process.

Lastly, the vendor will offer complete transparency by tracking, reconciling, and reporting on the progress of ESRD efforts and resulting financial outcomes.


Contact us today for more information about how Discovery Health Partners can improve your ESRD validation and premium restoration programs.

Discovery Health PartnersEnd-Stage Renal Disease (ESRD) FAQs
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Medicare Secondary Payer (MSP) FAQs

Today’s Medicare Advantage plans must manage payment integrity from two angles. First, they must ensure claims payments are accurate. And they must make sure that premium dollars coming in from the Centers for Medicare and Medicaid Services (CMS) are accurate. However, inaccurate member eligibility data often results in Medicare Advantage plans receiving fewer premium dollars than they’re owed.

Medicare Secondary Payer Validation is a key factor in quickly and accurately confirming CMS records, correcting inaccuracies, and restoring millions in underpaid premium dollars. Here are answers to a few frequently asked questions about Medicare Secondary Payer Validation.

What is Medicare Secondary Payer?

Medicare Secondary Payer, also known as MSP, is a term used by Medicare when another payer is primary, establishing that Medicare is the secondary payer. This applies to both Part C medical coverage and Part D prescription drug coverage. In both cases, the Medicare Advantage plan is paid a per-member monthly premium by CMS to administer the plan.

What is the financial impact of Medicare Secondary Payer to Medicare Advantage plans?

Premiums paid by the Centers for Medicare and Medicaid Services to Medicare Advantage plans are reduced 82% per month when other primary medical coverage exists. CMS puts the burden on Medicare Advantage plans to prove when they deserve primary premiums, and many plans don’t realize how much revenue they lose in underpaid premiums. The good news is that the Centers for Medicare and Medicaid Services allows Medicare Advantage plans to recover premiums from the previous 84 months.

Identifying inaccuracies in the CMS Common Working File is like looking for a needle in a haystack. How can this be more effective and efficient?

Finding inaccuracies and identifying primacy changes requires the right mix of data modeling, sophisticated tracking, and workflow technology. The key is to focus only on those records that have the greatest potential to negatively affect premiums.

Beyond identifying inaccurate records, how complex is the process?

There are several challenges and complexities in MSP validation. The plan may lack a dedicated or specialized team to focus on the problem, or there may be multiple points of ownership throughout the organization (e.g., claims and finance).

The validation process itself is complicated and time-consuming. It requires finding and contacting the other insurance provider, capturing and sharing validation data, and communicating with CMS to get the record corrected. Due to this inherent complexity, premium restoration is often delayed.

What do I need to consider when partnering with a Medicare Secondary Payer validation vendor?

Since MSP validation can have such a significant financial impact for Medicare Advantage plans, finding a Medicare Secondary Payer validation partner is wise. There are several factors to consider. Most important is making sure the vendor has expertise in the process.

In addition, the ideal partner will manage the entire process from start to finish, requiring minimal to no involvement from the plan. Rather than providing leads and stopping there, the vendor will make updates directly to the CMS source file and then monitor and report on the results.

The partner will back this up with the right mix of data modeling, sophisticated tracking, and workflow technology. The right validation vendor will also provide complete financial transparency and insight, helping to track, monitor, and reconcile the financial impact.

Lastly, the vendor will fill gaps in the Medicare Secondary Payer validation process, aligning the organization, simplifying compliance, bringing focus to validation activities—and providing measurable value.


Contact us today for more information about how Discovery Health Partners can improve your Medicare Secondary Payer validation and premium restoration.

Discovery Health PartnersMedicare Secondary Payer (MSP) FAQs
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DRG validation strategies for success

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

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

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

1. Analyze trends in data

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

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

2. Trust coders’ professional knowledge

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

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

3. Get clinical validation

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

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

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

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

Clarissa McCormick, RHIT, CCSDRG validation strategies for success
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The impact of telehealth on clinical audits during COVID-19

Nowhere is COVID-19 felt more acutely than in healthcare. Hospitals are overloaded, clinicians are overworked, and ICU beds are scarce. The pandemic has also had an effect on the ways in which we seek non-emergent care. Telehealth has become a welcome relief for patients who need to seek care but want to stay in the safety of their homes. It also helps providers remotely screen and monitor COVID-19 patients without putting themselves at risk. 

4,347% growth

in telehealth claims


$250 billion

stated telehealth market potential


7-fold growth

in telehealth projected by 2025


In response to the growing need for telehealth, the Department of Health and Human Services issued a waiver on March 6, 2020, allowing all Medicare beneficiaries in all areas of the country to receive telehealth services from home. Previously, telehealth was only allowed in rural areas from healthcare sites. The waiver relaxes several other regulatory guidelines including those surrounding HIPAA, copays, deductibles, and more.

While telehealth has become a lifeline during the pandemic, the potential for improper coding and documentation—and fraud, waste, and abuse—is high. Until reimbursement for telehealth is better understood, health plans are wise to include telehealth claims in their clinical audit programs.

New telehealth regulations

As they manage telehealth claims, health plans need to first fully understand the new payment requirements. There are three types of telehealth services that fall under the telehealth expansion waiver:

  • Medicare telehealth visits are visits with a provider via telecommunication systems that offer audio and video 
  • Virtual check-ins are brief, patient-initiated check-ins with providers via telephone or other device to determine whether an office visit or other service is needed
  • E-visits cover communications between a patient and provider through an online patient portal

The waiver also includes stipulations as to whether the patient must be an established patient. A range of providers including doctors, nurse practitioners, clinical psychologists, and licensed clinical social workers can offer telehealth services. In its fact sheet, CMS provides greater detail, as well as HCPCS and CPT codes for telehealth services. 

Telehealth payment risks

Relaxing telehealth regulatory guidelines has led to growing concern about a potentially heightened risk of improper payments. Concern has arisen around a few factors:

  • CMS has approved 135 additional temporary billing codes for telehealth services, and new information and guidelines are changing by the minute, causing confusion and raising the risk of error
  • Penalties for some HIPAA violations may be waived to encourage telehealth, though this raises concern for patient privacy and safety
  • States and the federal government have loosened state licensing restrictions, allowing providers to work across state lines, widening the potential for liability and malpractice repercussions
  • States like California have their own telehealth regulations, which are stricter than the federal government’s. These state regulations must take precedence

Telehealth in clinical audits

As telehealth continues to skyrocket and with relaxed guidelines, health plans need to begin including telehealth claims in their clinical audit programs. Claims need to be reviewed for legitimacy to spot instances of fraud. Plans need to validate that services are coded and billed correctly and verify that appropriate documentation is included in all claims. 

Telehealth has been making great inroads in helping to combat the COVID-19 crisis, but until it is better understood, health plans are wise to approach this uncharted territory with a dose of caution.

Learn more about Discovery’s Clinical Audit solution.

Lynn Walter, MBA, RN, COC, CCFAThe impact of telehealth on clinical audits during COVID-19
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Three benefits of physician oversight in clinical audits

As I discussed in my earlier blog post, clinical audits play a critical role in ensuring payment integrity for health plans. They help to identify where payment errors are likely and help to correct those errors.

Previously, we talked about the need to care for providers during clinical audits, reduce abrasion, and protect the payer/provider relationship. In today’s blog post, we take the discussion a step further, identifying how physician oversight plays a role in conducting medically sound audits that reduce provider abrasion and ensure defensible recoveries.

Let’s discuss three topics in more detail:

1. Reducing provider abrasion

When conducting clinical audits, health plans must consider the experience from the provider’s perspective. While there’s little disagreement in the medical community that clinical audits are necessary, they can be tedious and expensive.

There are a few techniques I’ve used to help deliver a positive experience during clinical audits, making them less intrusive and more cost-effective for both parties. Education and transparency can have a significant impact on enhancing the provider experience. Clearly communicating expectations, requests, deadlines, and the plan’s findings go a long way toward improving the payer-provider relationship.

By being involved in these audits, I have come to realize that physician oversight helps to ensure a positive provider experience. When providers know that audits are medically sound and have been reviewed by a physician, they more readily accept the outcomes of the audit.

2. Providing the clinical perspective

When payment integrity is the goal, financial decisions cannot be the primary concern for both payer and provider. With physicians involved in the process, it’s understood that finances are not the motivating factor. By involving physicians, plans have the opportunity to communicate to providers that it’s not all about money and that there is clinical consideration given to audits.

In addition, physicians can help providers understand the medical rationale behind identified payment inaccuracies. We can help communicate compliance rules and show providers where they may have gone wrong in their coding and documentation practices. Ultimately, this helps providers learn from the audit and are more compelled to change their behavior.

3: Ensuring medically defensible recoveries

Whenever a clinical audit leads to the recovery of overpaid funds, the health plan must ensure that all clinical audit outcomes are defensible. Physician oversight helps ensure that audit decisions are made with clinical objectivity.

This is particularly true with medical necessity discussions. With high-dollar claim reviews and DRG validations, physicians collaborate with coders in developing review algorithms. In responses to appeals, physicians can review the audit decision and provide the clinical justification for the outcome.

In the end, physician oversight in clinical audits helps health plans ensure they are effective and reduce any abrasion that might be experienced by the provider. The physician can engage in peer-to-peer discussion with the provider and help them understand audit decisions from a mutually agreeable clinical perspective.

Learn how Discovery Health Partners can help you enhance the medical validity of clinical audits.

Moira Dolan, M.D., is Medical Director for Discovery Health Partners. She is a graduate of the University of Illinois School of Medicine and has been a practicing physician for over 30 years. Dr. Dolan maintains a private medical practice in Austin, Texas.

Moira Dolan, M.D.Three benefits of physician oversight in clinical audits
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Your COB questions answered

As we meet with health plans of all shapes and sizes across the country, we’re frequently asked for advice regarding the Coordination of Benefits process, vendor selection, and orchestration with internal COB teams. Here, we share several of the common questions and our responses. 

Why consider Discovery Health Partners’ COB solution?

Your health plan’s success is based on the speed and accuracy of claims payments. Up to 15 percent of all members have other health insurance in any given year, costing plans millions in higher payments and administrative costs.

The Discovery COB solution is designed to go beyond other COB vendors by identifying more members with additional coverage—leading to less provider and member abrasion, additional claims recoveries, and avoided future expenses. Leveraging the power of technologies like Artificial Intelligence (AI) and predictive modeling, Discovery effectively integrates both traditional and non-traditional data sources to identify and determine the most successful indicators or combination of indicators of other coverage. We then use this information to automatically update analytic models to reflect that learning.

Does our organization need to change our existing COB processes?

No, your organization does not need to change its existing COB processes. Our COB solution is designed to work in concert with your existing internal and/or external vendor processes by harnessing the power of data mining and analytics to identify additional opportunities for recovery. To minimize duplication of efforts, our highly experienced staff works in partnership with your in-house COB, Operations, and IT teams. This enables your organization to retain current staff and gain additional savings. Our solution provides health plans with a “safety net” that delivers considerable incremental recovery opportunities with minimal disruption to operations.

How is Discovery’s COB solution different from internal operations or external vendors?

We built Discovery on both our staff’s deep subject matter expertise and the experiences learned while delivering successful payment integrity programs. Unlike traditional vendors that heavily rely on direct outreach, Discovery’s COB solution combines advanced technologies and extensive healthcare expertise to look at member eligibility more holistically, resulting in an increased number of high-value opportunities often missed by traditional means.

What does Discovery’s COB process look like?

Discovery takes a very flexible approach to its COB solution to accommodate different clients’ needs. Some of the options we offer with our COB solution include: mirroring a client’s internal COB team approach, acting as a turnkey vendor for COB efforts, focusing our COB efforts on all lines or business, and performing COB for only certain LOBs and/or claim types.

Does line of business matter?

No, line of business—whether commercial, Medicare, or Medicaid—does not matter. Discovery’s extensive knowledge of the various rules and regulations for each line of business allows us to perform COB services for all your covered lives. Discovery’s propriety algorithms and mining efforts are customized to deliver the most value possible across all your lines of business.

What should our organization look for when evaluating COB vendors?

The payment integrity market includes a wide range of COB vendors who offer to maximize recoveries and prevent future costs. When evaluating vendors, here are some things to think about:

Data: Where is the potential vendor getting its data and is the data relevant to your plan?

Expertise: What type of clients does the COB vendor work with today? Are they specialized in one line of business or do they work across multiple? Does the vendor have folks with plan-side experience?

Satisfaction: Does the vendor have a track record of delivering value to its clients?

Flexibility: Is the vendor flexible enough to wrap around your current team?

Technology: Is the vendor using technology like AI and machine learning to look at eligibility more holistically?

Research and development: Is the vendor relying on standardized practices that “worked before”? Or do they have a team of seasoned research analysts dedicated to looking for new rules, regulations, data sources, and data points to deliver additional value?

Full-service capabilities: Does the vendor offer solutions spanning all phases of the claims lifecycle (e.g., prospective, retrospective, hospice, etc.)?

Security: Is the vendor HIPAA and HITRUST compliant? What security standards and access policies are in place?

Partnership: Is the vendor willing to learn about your organization, what’s important you, and how to support your COB process and goals? Is this a joint collaboration and journey? Where does your plan line up with the vendor’s other clients? Will you be a priority for them?


Discovery is more than just another vendor—we are your partner, looking out for you every step of the way with proactive insight and information. Is this what you’re getting today? Learn more about our Coordination of Benefits solution.

Discovery Health PartnersYour COB questions answered
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Trends that are re-shaping payment integrity strategies

Evolving payment models and new technologies are supporting health plans’ efforts to implement more proactive, data-driven payment integrity solutions. Diane Akrami, Senior Director, Audit Operations, discusses what’s in store for the future of payment integrity and how the company is helping clients make the transition from retrospective to prospective programs.

During the last decade, a number of emerging trends have impacted health plans’ ability to reduce their exposure and increase payment accuracy. Value-based contracting, for example, has left many payers struggling to figure out how to transition to the performance-based payment methodologies that center on cost efficiency, quality, and delivery standards. The changes around CMS’ reimbursement models for home health and skilled nursing can pose some challenges as provider and payers adapt to those changes and create new PI audit opportunities. Payment integrity programs can provide needed support in adapting to claims processing changes like these.

At the same time, providers themselves are evolving and making changes to their billing processes based on these new models. In order to mitigate potential payment errors, health plans are moving from a retrospective process of identification and recovery to a more cost-effective prospective approach. Through clinical audits focused on the provider type, place of service, and their reimbursement models, plans can verify that services billed were performed, ensure proper payments, and avoid the costs of recovery. Payment integrity has a role to play here. Focused payment integrity programs that take a holistic approach to claims auditing enable health plans to shift from cost recovery to prevention and cost avoidance, thereby increasing claim payment accuracy.

Helping transform payment integrity approaches

As industry needs change, Discovery has been bolstering our payment integrity capabilities with experienced talent, technology platforms, and analytical tools. Our highly-experienced Clinical Audits team builds and deliver solutions for urgent care, home health, skilled nursing facilities, high-cost drugs, and other standard and client-specific audits, Our client-centric approach to payment integrity will allow us to continue expanding these types of services to address health plans’ needs as they arise—specialty audits for provider telehealth claims, for example—to support our clients’ cost avoidance and recovery operations.

Using data to evolve payment integrity approach

The healthcare industry is accelerating its adoption of cutting-edge technologies like artificial intelligence and machine learning to add efficiency and cut costs across operations, including in the payment integrity space. Discovery leverages analytics, artificial intelligence, and machine learning to audit millions of claims every month and find the “needle in the haystack” claims that yield the highest savings for health plans. We are also using analytics to identify patterns in client data that are specific to that provider. We can use that information to educate clients on how to address specific trends to improve their billing processes. We can also help them identify opportunities to change behaviors, so they are able to pivot to a proactive payment process.

Health plans are looking for a true partner who can help them support and enhance their payment integrity efforts so they can better control costs associated with incorrect billing and overpaid claims and improve administrative and medical loss ratios. With years of experience supporting both payment integrity and managed care, Discovery’s connected payment integrity approach—combined with our dedication to partnership, responsiveness, and relationships—delivers results that go far beyond financial value.

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

Diane AkramiTrends that are re-shaping payment integrity strategies
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Caring for providers during clinical audits

For today’s health plans, clinical audits play a critical role in ensuring the financial health of the organization. They can help a plan control costs, comply with government regulations, and meet financial requirements. Fundamentally, clinical audits help to identify where payment errors are likely. There are many flavors of clinical audits—reviews for high-dollar claims, medical necessity, hospital bills, DRG validation, and skilled nursing care are among some of the most common.

Effect of clinical audits on providers

Whatever the flavor of the audit, it’s likely that clinical audits can create provider abrasion. As a medical director, I have experienced clinical audits and understand the reasons for the discontent. There’s little disagreement in the medical community that clinical audits are necessary, yet tedious and expensive.

In fact, nearly a third of providers report a negative experience with payer audits, according to a recent study by Frost & Sullivan. Providers report that their negative experience stems from factors including a high volume of medical requests, the prevalence of technical denials, and the high administrative costs of audit compliance.

More than 92% of survey respondents tie provider abrasion to the volume of medical requests. And 50% of providers consider clinical validation audits and DRG coding to be very or extremely labor-intensive. This is a critical factor given that labor intensity has a direct impact on administrative costs.

Improving the payer-provider relationship during audits

The good news is that any dissatisfaction in the clinical audit process is not irreparable. I have learned that provider-friendly techniques can go a long way toward delivering a positive experience during clinical audits, making them less intrusive and more cost-effective for both parties. Recognizing that clinical audits have the potential to cause provider abrasion is the first step to reducing discontent. Beyond that, communication and education are key.

Clear and transparent communication throughout the clinical audit process can have a significant impact on enhancing the provider experience. By clearly communicating expectations, health plans can alleviate provider unease with the audit process and mitigate the adversarial impact and stress related to clinical audits.

Providers are more likely to be amenable to the audit when they clearly understand requests, deadlines, and the plan’s findings. When they know what to expect and understand that the communication lines are open, providers are more likely to have a positive experience.

Similarly, education is an important tool in reducing provider abrasion. Perhaps the most valuable element of clinical audit education is helping providers understand how to change their behavior to reduce the impact of audits. Health plans can educate providers on the need for preventative measures in situations related to high-risk targets. Education can also include helping providers understand how to implement a proactive approach to address recurring problems.

Ultimately, with frequent and transparent communication and education throughout the clinical audit process, health plans can help providers view the plan in a favorable light and experience the audit without undue stress. With a positive clinical audit experience, payers and providers can work together to reduce the potential for post-payment recovery today and in the years to come.

Learn how Discovery Health Partners can help you enhance the provider experience in clinical audits.

Moira Dolan, M.D., is Medical Director for Discovery Health Partners. She is a graduate of the University of Illinois School of Medicine and has been a practicing physician for over 30 years. Dr. Dolan maintains a private medical practice in Austin, Texas.

Moira Dolan, M.D.Caring for providers during clinical audits
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