A closer look at one of 2017’s top payment integrity trends. Health plans are making a concerted effort to focus more of their payment integrity resources on avoiding inaccurate claims payments up front, rather than recovering erroneous payments on the back end.
As cost reduction continues to take center stage, healthcare payment integrity is in the spotlight. Increasingly, health plan executives are recognizing the power of payment integrity functions to add significant value to a health plan’s bottom line by improving the plan’s ability to recover or avoid improper claims payments and improve accuracy of premium revenue.
Though MA plans are on the task – attempting to find and correct errors in member eligibility and CMS premium payments – most are still missing millions of dollars due to hidden challenges in the process.
Maintaining a high level of customer service and solution quality is challenging in any industry. And because our customers are in the highly-regulated market of healthcare and health insurance products, the services and outcomes we provide are under almost as much scrutiny as the plans we serve.
This topic has been evolving for more than 10 years as litigation and case law have disputed over the issue of whether the private cause of action for double damages under the Medicare Secondary Payer (“MSP”) Act provides Medicare Advantage (“MA”) Plans with the right to bring suit against primary payers.
For many health plans, payment integrity is able to influence the bottom line in powerful ways. For payment integrity organizations (sometimes called cost containment), the new year is the perfect time to evaluate what has been working well and what can be done better and more efficiently.
(Michele Stuart of JAG Investigations’) presentation was alarming and fascinating as she showed us how vulnerable our social media activity makes us to criminal activity and walked us through steps we can take to protect ourselves.
As the healthcare industry continues to transform, it has become clear that the need for increased transparency is one of the critical drivers of change. Health plans are being asked to share more information with a broad range of stakeholders in an effort to control costs and drive improvements in efficiency.
CMS premiums have a direct impact on your bottom line and there’s a good chance that you’re not receiving the full premiums you’re owed. In fact, you may be getting shorted by millions of dollars in premiums due to MSP.
For many health plans, payment integrity is able to influence the bottom line in powerful ways. For payment integrity organizations (sometimes called cost containment), the new year is the perfect time to evaluate what has been working well and what can be done better and more efficiently. And often payment integrity technology is one of
With all of the demands on your team, your time, and your resources, eligibility data management may not be your first priority. In our experience with over 15 health plans, eligibility data issues are the root cause of between 20% and 30% of payment integrity costs.
Addressing eligibility data management can seem like an overwhelming or impossible task among all of your other competing priorities. However, fixing these data errors can eliminate downstream impacts to your payment integrity programs that are likely costing your plan millions of dollars.
Over the last two months, we’ve examined how organizational and technology structures can keep health plans from recognizing, understanding, and resolving their payment integrity challenges. This month, we want to spend a little time examining one thing that can be at the root cause of some of those challenges: eligibility. Eligibility issues impact a multitude
By Bill Whittemore, vice president of Ajilitee, Discovery Health Partners’ sister division In my last blog post, I discussed some of the challenges healthcare payers face related to their lack of transparency into recovery performance results at a program level. In this post, I’d like to dive deeper into the problems caused by lack of
By Bill Whittemore, vice president of Ajilitee, Discovery Health Partners’ sister division Several months ago, I wrote a blog post discussing the challenges that cause health plans to lose money on their claims payment integrity programs. In this post, I’d like to dive deeper into the problems caused by insufficient technology and dispersed payment integrity
In their ongoing efforts to manage costs and improve profits, many health plans are turning to the area of claims payment integrity, where plans are finding opportunities to reduce annual claims expense by millions of dollars. Despite the compelling business case for payment integrity, many health plans find that organizational challenges often mask these
Clearly healthcare is the most interesting and dynamic sector in the U.S. today. We are witness to an unprecedented transformation as healthcare stakeholders embrace new delivery entities and new reimbursement models, shift attention to building relationships with members, and explore new markets. There will be winners and losers in this game, and everyone is placing
The Discovery Health Partners team spent some time earlier this week digging into Medicare at the Health Education Associates Medicare Accounting and Reconciliation conference. We were certainly excited to escape the snow and cold of the Midwest with a couple of days in Florida, and we were (almost) as excited to hear what our health
Joint replacement surgery is fairly common in the United States, with more than 285,000 hip replacement surgeries every year. However, if that new hip turns out to be defective—causing further pain or weakening of the joints—this routine hospital procedure could become subject to the complexities of mass tort litigation. What is mass tort? Mass tort
As the old saying goes, “You can’t improve what you don’t measure.” Imagine you are a student taking a test and never knowing your grade. It’s nearly impossible to strategize a plan for improvement if you are unaware of your current performance. This same principle applies to subrogation cases. Analytics are essential to evaluating the
Once you have identified which subrogation cases have recovery potential and which do not, it’s time to make sure you are optimizing program performance in three key areas: Platform – leveraging technology and automation to improve results Process – evaluating recovery workflows to ensure efficiency is maximized by leveraging available technology People – recruiting and
No one wants to leave money on the table. But that’s often what happens when health plans don’t recover payments for claims that are someone else’s financial responsibility. A health plan’s successful recovery of injury-related claims depends upon a fine-tuned and optimized subrogation process. In our three-part series, “Next-generation subrogation solutions,” we offer effective strategies
When it comes to premiums, many Medicare Advantage (MA) plans are being underpaid because of incorrect Medicare Secondary Payer (MSP) adjustments. It’s a known problem – Commercial plans mandatory Section 111 reporting creates instances of other coverage for a member. This flags the MA plan as the secondary payer for that member resulting in a negative
Assess the transparency of your recovery programs conducted in-house or by vendors. This self-evaluation tool will help you determine “the transparency factor” in your initiatives. Take our Transparency Assessment Survey to learn more.
Healthcare payment integrity: the process of ensuring that a health claim is paid correctly—by the responsible party, for eligible members, according to contractual terms, not in error or duplicate, and free of wasteful or abusive practices. Payment integrity uses data mining and analytics to identify fraudulent, erroneous, or abusive claims, supports resolution with improved workflows,