Eligibility data management: Fixing payment integrity at the source

With all of the demands on your team, your time, and your resources, eligibility data management may not be your first priority. After all, you have to focus on maximizing recoveries and avoiding costs. Which is exactly why you should consider evaluating your current eligibility data management structure and processes. In our experience with over 15 health plans, eligibility data issues are the root cause of between 20% and 30% of payment integrity costs.

Claim recovery

Accurately determining which claims have been paid incorrectly due to eligibility data errors for your plan can streamline your recovery efforts to ensure maximum efficiency and results. We estimate that 20% of a plan’s membership will have other insurance and of that 20%, the other insurance will be primary 17.5% of the time. For a 200,000 member plan, this represents nearly $5.4 million in incorrectly paid claims. We believe with the right solutions and expertise, health plans can expect to recover a significant portion of those claims.

Cost avoidance

Of course, if your eligibility data is accurate and trusted, your plan won’t have to worry about recovering dollars from incorrectly paid claims. You will be able to avoid paying them altogether by paying claims correctly the first time. For that same 200,000 member plan, our experience indicates the savings by avoiding those incorrect payments through the use of accurate and trusted eligibility data is over $13.4 million.

Administrative efficiency

In addition to the recoveries and restorations that go directly to your bottom line, you should also consider the time and expense associated with rebilling or recovering inaccurate claims payments. Identifying, processing, recovering, and rebilling incorrectly paid claims has a significant cost in terms of time, money, and personnel. By eliminating the need to rebill, you save valuable time and energy that can be channeled toward other payment integrity initiatives.

Member satisfaction

In the increasingly competitive consumer driven health insurance marketplace, health plans are focusing on member satisfaction as a strategic priority, and accurate eligibility information is a critical component. Claims that are declined due to inaccurate or out-of-date eligibility data can lead to member abrasion, lost market share, and reduction in STAR ratings.  Eligibility data impacts more areas of a health plan than any other data set.  Eligibility data drives a diverse number of systems and processes include signup, enrollment, care provision, wellness, customer care, and even termination. All of these areas influence your member’s experience with your plan.

Provider relations

Claims denied due to eligibility issues can lead to provider abrasion, increased costs for rebilling, and can damage network affiliations. Provider operations and, more importantly, their revenue cycle management, are largely dependent on accurate eligibility data. Reductions in administrative expense and increases in financial accuracy are passed on to providers, and can deliver substantial benefits through improved provider relations while reducing any potential negative impacts between members and providers .

The Discovery Health Partners team has seen first-hand how creating a single, trusted source of accurate eligibility data has helped health plans improve in each of the above areas and has additional benefits across your health plan and the entire healthcare ecosystem. By leveraging multiple data sources and employing predictive data mining and analytics, we are able to verify and update eligibility status and make it available to claims adjudication systems and other downstream applications. To learn more about our solution and how it could impact your bottom line, visit our Eligibility Management resource page.


Paul VostersEligibility data management: Fixing payment integrity at the source
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The right eligibility data management solution

Last month, we identified how eligibility data errors may be undermining your health plan’s payment integrity efforts. Certainly there are many factors to consider when correcting erroneous eligibility data, but the bottom line is this: in order to maximize payment integrity outcomes, health plans need a single, accurate, trusted source of eligibility data.

It sounds simple enough, but, like many health plans, you may be left wondering how to begin addressing this issue.  Although you may already have a team of talented, hard-working individuals, navigating the complex world of eligibility data can be much easier with an experienced partner and a proven service solution.

Let’s take a look at some of the critical components an eligibility data management service solution must have to help maximize recoveries and drive ongoing cost avoidance.

Comprehensive data mining

Accurate eligibility determinations require the seamless integration of data from multiple resources, along with powerful data mining capabilities to identify potential issues. This means your vendor will help you proactively identify more instances of other coverage by utilizing every available, relevant data resource.

  • Examine your health plan’s commercial coverage claims and eligibility information
  • Validate leads, determine primacy, and update eligibility for all other data sources including data-match vendors, Section 111 reporting, MSP files, and provider bills

A proven process

The right solution leverages a proven process to identify potential cases, investigate the appropriate data sources, and correctly apply the NAIC rules to determine primacy. The process should be built on transparency between you and your vendor so that you have insight into each step and a clear understanding of the expected and actual results.

Superior analytics

The right solution relies heavily on advanced analytics to determine primacy and make eligibility decisions. However, the analytics engine needs to be flexible enough to accommodate your plan’s specific data sets and needs. Your vendor should work with you to understand your current data, identify the largest opportunities, and create a strategy and approach that address your plan’s specific priorities.

Transparent reporting

The right solution isn’t a black box. You and your team should have full visibility into your vendor’s performance. A standard report package should include eligibility update and inventory reports that allow you to see progress on a weekly and monthly basis. But, you should also have the ability to customize report content and frequency to meet your plan’s specific needs.

Dedicated partnership

The right solution isn’t from a vendor at all, it’s from a partner. Align your plan with a partner that is dedicated to improving your busi­ness processes and your bottom line. Their team should complement yours in their knowledge, approach, and experience. And their results should be proven, referenceable, and demonstrable.

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. Next month, we’ll show you just how big those impacts can be in our blog post that will highlight the results of implementing a service solution like the one we’ve described above.


For more information…

Would you like to learn more about Discovery’s payment integrity solutions and how they can help you improve recoveries and premium restoration? Just complete the quick survey below for more information and custom demos.



Paul VostersThe right eligibility data management solution
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The eligibility impact: How and why eligibility data issues affect payment integrity

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 of payment integrity areas, including Coordination of Benefits and Medicare Secondary Payer validation, and, to a lesser extent, Workers’ Compensation, Other-Party Liability, and Subrogation. In fact, Discovery Health Partners’ research indicates that approximately 30% of payment integrity costs are driven by eligibility errors. In addition to the financial cost of payment integrity errors, eligibility issues can also have a direct effect on member satisfaction. Claims that are declined due to inaccurate or out-of-date eligibility data can lead to member abrasion and lost market share.

At their core, these issues all stem from the fact that health plans lack a single, definitive resource for making eligibility status determinations prior to paying a claim. This creates tremendous downstream issues as health plans make business decisions and pay claims based on flawed data.

The complex structure of health plans means that member eligibility is updated at multiple points in the claims payment process and is managed by multiple departments across the organization. As a result, it’s often inconsistent, outdated, or inaccurate, and leads to improper claims payments. Until plans are able to establish a single source of the truth for eligibility, these inaccuracies can cost plans millions of dollars. Let’s examine a few of these challenges more closely:

Multiple data sources

The sheer number of data sources feeding the master eligibility file has a significant impact on accuracy. Information comes from the members, providers, CMS, data-match vendors, and other data sources. These feeds are all subject to their own timelines, standards, and information challenges. In addition, these external feeds to eligibility status have a high rate of change, creating a complex hierarchy of overlapping status updates. Plans are challenged to manage these work processes and make a clear determination of primacy and eligibility that can support all of the transactions that rely on this data.

Organizational challenges

The eligibility challenge isn’t just technical, it is also frequently organizational. Eligibility is commonly managed by line of business, meaning that status updates made by one group are not necessarily shared across the organization. For example, changes in a member’s eligibility status might not be effectively communicated between the commercial and government lines of business as the member moves from commercial to Medicare Advantage coverage. With no clear owner of the member eligibility status, managing the data across departments adds an additional level of complexity.

Existing solutions

In addition to being spread out across different departments, responsibility for managing eligibility status is shared by several administrative systems. Plans often make the mistake of addressing eligibility in a single point solution, rather than taking an enterprise view of member eligibility management. Claims and enrollment systems often fail to address eligibility on a consistent transactional basis, and frequently capture crucial updates in notes or text format. Eligibility data is rarely shared between systems, and because there is no single data master, the priority of status changes is unclear.

Looking to the future…

Health plans have the opportunity to dramatically improve their payment integrity performance and member retention by managing member eligibility as a business asset. The ideal solution will provide a complete and integrated picture of eligibility status across membership types and lines of business, while providing validated data for downstream applications. Doing so will require a shift in culture, as well as new technologies. Nonetheless, there are strategies that let you achieve progress in a staged progression, which we will explore in future posts. Managing eligibility data as a strategic asset is worth the effort, as it will result in millions of dollars in recoveries and cost avoidance.



For more information…

Would you like to learn more about Discovery’s payment integrity solutions and how they can help you improve recoveries and premium restoration? Just complete the quick survey below for more information and custom demos.



Paul VostersThe eligibility impact: How and why eligibility data issues affect payment integrity
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Whitepaper: Innovations in cost containment for healthcare payers

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Discovery Health PartnersWhitepaper: Innovations in cost containment for healthcare payers
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Discovery Health Partners expands offerings with Eligibility Solutions

New Solutions Validate Eligibility Data with Speed, Efficiency and Minimal Impact

ITASCA, IL (September 17, 2013) – Discovery Health Partners today announced that it has expanded its Intelligent Cost Containment solutions portfolio with new Eligibility Solutions that enable faster, simpler collection and sharing of eligibility data among payers, providers and employers.  These Eligibility Solutions focus on the collection, maintenance, and integrity of eligibility data through data validation, record update and membership surveys.

“The process for capturing and storing eligibility data is extremely complex. Not only is it difficult to gather eligibility data consistently across all membership, but also maintaining accurate records is challenging because the data constantly changes,” said Paul Vosters, President and Chief Operating Officer, Discovery Health Partners. “Our Eligibility Solutions help customers to manage eligibility data more strategically.  We create a single, trusted source of eligibility data that can feed critical claims decisions and cost containment initiatives.”

Discovery Health Partners’ Eligibility Solutions include the following:

  • Eligibility Assessment, an in-depth analysis based on current eligibility processes and dependencies that maps out best practices, tools, and processes needed for higher levels of efficiency and quantifiable results.
  • Eligibility Integrity, which helps clients avoid incorrect claims payments by analyzing all sources of eligibility data to identify inaccuracies, make updates, and maintain eligibility data correctly.
  • Medicare Secondary Payer (MSP) Validation and Premium Restoration, which actively validates MSP records, correct inaccurate records, and restore premium dollars that have been underpaid due to record inaccuracies.   
  • Medicaid State File Validation, which confirms the validity of other coverage information collected by the state through its mandatory reporting.
  • Section 111 Mandatory Reporting, which enables group health plans to comply with CMS mandatory reporting requirements while harnessing the power of eligibility data that is exchanged to pay claims correctly at first billing.
  • Employer Group Reporting, which helps healthcare payers provide insight and transparency to employers so they can identify trends, evaluate participation, design and improve employee health plans, and compare performance against other employers in the same plan.
  • Survey, which enables health plans to connect with their membership using various response channels to get needed information to improve process, avoid costs, and preserve program integrity.

The new Eligibility Solutions are managed by seasoned U.S.-based staff members with expertise in eligibility, healthcare law and data management and understand the disparate nature of eligibility data collection and maintenance in healthcare organizations. Coupled with this hands-on knowledge, Discovery Health Partners’ proprietary Intelligent Cost Containment Platform provides tools and applications for process management, data integration, reporting, and analytics to help automate workflow and integrate eligibility data across multiple systems.

“We build a foundation for a more efficient claims process, improved employer group reporting, and more accurate Medicare and Medicaid compliance and reporting,” said Vosters.  “With health payers facing mounting pressure to manage cost, streamline processes, improve quality, enable compliance, and also improve employer satisfaction and retention, our Eligibility Services align with our entire suite of payment integrity solutions to deliver measureable results against these priorities.”

















Discovery Health PartnersDiscovery Health Partners expands offerings with Eligibility Solutions
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