How payment integrity is evolving

Finding the best return on investment

You have been involved with payment integrity for quite some time. How have you seen it evolve over the past 15 years?

James Brady: Payment integrity (PI) started decades ago as a clean-up function to help when there were claim processing errors. It has evolved into a much broader capability which can address a wide range of medical claim payment errors such as inaccurate coding, duplicate payments, and contractual mistakes. 

Not surprisingly one of the biggest drivers of evolution in the PI industry has been advances in technology. Technology made it possible to go deeper when looking for overpayments and broader too, meaning we can review a lot more data than in the past. Another big shift has been to prepayment from postpayment. For many years, PI was focused on identifying and recovering overpayments already made by the plans in error to providers. Now there is great interest in paying providers appropriately from the beginning so that the system runs more smoothly. This can have a big impact on lowering provider abrasion and improving the overall health of the healthcare system. 

Another evolution has been the consolidation of a lot of the original PI players which has limited PI vendor choice for plans. At the same time there has been a proliferation of small, hyper focused vendors that focus on a single specialty. One example of this is "Edits." Claim editing is a good first line of defense in a plan's prospective PI program and is based on following guidelines and rules from organizations like the Centers for Medicare & Medicaid Services (CMS), and the American Medical Association (AMA), and codifying them into claim editing rules. A vendor that only does that, but does it very well, is a valuable piece of the claim payment lifecycle continuum review. 
 

From reactive point solutions to end-to-end solutions

How is Carelon leading payment integrity innovation?

Jeff Plante: Carelon was born out of one of the nation's largest health plans, and so is in the enviable position of having a lot of data and a lot of expertise to draw on.  We can develop end-to-end solutions based on hundreds of millions of claim payment transactions. So, our PI approach, similar to the approach we take for our other Carelon services, is comprehensive, collaborative and forward thinking. 

The advanced analytics, sophisticated technology, and our unique approach translates to breaking down siloes and connecting the healthcare system in powerful ways. We tailor what we do, and are accessible, keeping affordability always top of mind. We know that when the healthcare system is healthier, better outcomes are possible for our clients, for providers and members and for everyone. 

 

Applying the right technology 

How does technology play into those capabilities and enhance them going forward?

James Brady: Our industry can only remain relevant if it is innovating on pace with the healthcare industry. We use the latest technology and develop advanced analytics to help us stay ahead of the curve. We rely on ideation teams, feedback loops, and client results to point the way to continuous improvement. Our experts, with their decades of experience and their willingness to go the extra mile, drive client success. 

Jeff Plante: Technology is the foundation of everything we do. At Carelon, we see how enormous the impact of the right technology can be on the healthcare system. Even the most complex problems out there can be addressed if teams are properly empowered and have the resources they need. We are constantly innovating, developing solutions that connect the right people to the right information. We develop solutions that help payers keep costs down, and help providers bill correctly. With the right partner, plans and providers can rest easy.

 

Identifying and solving “hidden” problems

Do you have an example of a solution or product that embodies this approach?

James Brady: Definitely. Many plans are unaware of the exact amount of money that is wasted due to overpaying providers through fraud, waste or abuse. In PI, the hardest area to nail down is the waste associated with coordination of benefits (COB). Our Coordination of Benefits Solution has helped us save billions of dollars for our clients by quickly and irrefutably identifying the responsible payer order for claims. Most health plans have a coordination of benefits program, but many of them aren't very successful because of the complexity of COB. It is typically done mostly manually, and it is expensive, and complicated. Payers typically lack the expertise or resources to do it themselves, and when outsourced sometimes find themselves dealing with too much provider abrasion. 

Jeff Plante: Our approach is to get member eligibility correct as early in the member journey as possible to create a frictionless experience for our members, providers, and customers. Sometimes members aren't sure in a given situation which insurance applies if more than one is involved. When other insurance may come to bear on a claim, we accelerate the identification of other health insurance coverage that members might have and streamline the process of determining the responsible primary payer. Leads can be processed faster, more accurately, and more efficiently. That means we can process an increased volume of leads and increase our clients' return on investment relieving much of the tension with providers that COB can cause. 
 

Getting it right the first time

Where is payment integrity headed?

James Brady: We think there will be even more of a reliance upon technology as PI continues to evolve. We also think there will be more integration of solutions and systems, more transparency and collaboration, and more of that shift to prepay to promote payment accuracy before claims are submitted. A lot of errors happen because billing and coding rules are just so complex - it's not intentional.  With our expertise, when we create better transparency, and leverage more sophisticated technology, we can break that cycle of claims being rejected or denied. We want to improve the health of the healthcare system. We're all in this together and our partnership approach reflects the care we take in what we are doing. 

Jeff Plante: Solving big-picture challenges requires bold ambition, deep expertise, and powerful capabilities. At Carelon, we have all three. Our mission is to improve affordability, reduce complexity, and drive better outcomes by challenging ourselves to excel. We help clients find success in a complex healthcare system.  When we join forces, the opportunities are boundless.