23Apr

The Power of Measurement and Pilot Programs in Payment Integrity

The Power of Measurement and Pilot Programs in Payment Integrity

In the world of healthcare payments, accuracy is everything. Lost revenue due to errors and improper claims can significantly impact an organization’s financial health. That’s why building a strong payment integrity program is crucial, and a key element of that program is measurement.

As a veteran in Payment Integrity, I’ve seen firsthand the power of data-driven decision making. Here’s why measurement is lesson number six on my list for successful program implementation:

  • Identify Areas for Improvement: Without measuring results, it’s difficult to know where your program is excelling and where it falls short.Metrics help pinpoint areas with the highest error rates or potential for improper payments. This allows you to focus your resources and refine your strategies for maximum impact.
  • Demonstrate Program Value: Leadership needs to see the program’s worth. Regularly measuring and reporting on recovered funds, identifying errors, and preventing improper payments provide concrete evidence of program effectiveness. This data becomes a powerful tool to secure continued support and resources.
  • Fuel Continuous Improvement: The healthcare landscape is constantly evolving. What works today might not be optimal tomorrow. Measurement allows you to track program performance over time and identify areas for improvement. This iterative process keeps your program agile and adaptable to changing regulations and industry trends.
  • Boost Staff Morale: When staff sees the program making a tangible difference, it boosts morale and fosters a sense of accomplishment. Sharing metrics around recovered funds or prevented errors can motivate staff and inspire them to continue their efforts.

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Curate Partners: Experts in Extracting  Payment Insights

Our team goes beyond basic metrics. We use advanced data visualization to uncover hidden patterns in your payment data, helping you identify high-potential areas for recovery.

Scalable Measurement for Your Program

We understand your needs are unique. We will work with you to build a customized measurement plan, starting with core metrics and seamlessly integrating more data points as your program matures.

Partner with us to leverage our expertise and advanced tools. Transform data into actionable insights and achieve long-term financial success.

VP of Healthcare Consulting at Curate Partners

Meet the Author

Chad Roswick, VP of Healthcare Consulting

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The material and information contained in this resource is for general interest purposes only and is based on our experience; it does not constitute financial, legal, or investment advice.
16Apr

Accelerating Payment Integrity: The Power of Internal Resources in Healthcare Operations 

Accelerating Payment Integrity:

The Power of Internal Resources in Healthcare Operations

In the dynamic landscape of healthcare operations, the pursuit of payment integrity stands as a crucial imperative. At the heart of this endeavor lies the strategic utilization of internal resources, whose expertise and advocacy can significantly accelerate progress. In this article I detail how leveraging internal assets can drive success in payment integrity initiatives within healthcare organizations.

Maximizing Expertise

Experienced professionals in payment integrity bring a wealth of knowledge to the table, offering invaluable insights that propel programs forward. Their seasoned perspective allows for a deeper understanding of industry nuances and challenges, ultimately accelerating the pace of progress.

Advocating for the Health Plan's Interests

While vendor solutions play a vital role in expanding payment integrity capabilities, internal resources serve as staunch advocates for the health plan’s interests. Their ability to evaluate vendor opportunities while balancing potential provider abrasion ensures alignment with organizational objectives and priorities.
healthcare internal

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Internal team

Navigating Data Limitations

Internal resources possess a keen understanding of data limitations, recognizing potential pitfalls that may lead to high false positive rates for vendor solutions. By leveraging this insight, organizations can mitigate risks and optimize data utilization, enhancing the effectiveness of payment integrity initiatives.

Building Internal Processes

Successful implementation of vendor solutions hinges upon the establishment of robust internal processes. Internal resources play a pivotal role in this endeavor, leveraging their expertise to design and implement workflows that support the integration of external innovations. This ensures seamless collaboration between internal teams and vendors, driving efficiency and effectiveness.

In conclusion, the strategic utilization of internal resources is paramount in accelerating payment integrity initiatives within healthcare operations. By maximizing expertise, advocating for organizational interests, and navigating data limitations, organizations can drive meaningful progress towards achieving payment integrity goals. With internal resources at the helm, healthcare organizations can unlock new levels of efficiency and effectiveness in their pursuit of payment integrity excellence.

Reach out to us to explore how we can support your organization’s Payment Integrity transformation!

VP of Healthcare Consulting at Curate Partners

Meet the Author

Chad Roswick, VP of Healthcare Consulting

Link to bio

The material and information contained in this resource is for general interest purposes only and is based on our experience; it does not constitute financial, legal, or investment advice.
09Apr

Navigating the Path to Payment Integrity: Crafting a Clear Roadmap for Success

Navigating the Path to Payment Integrity:

Crafting a Clear Roadmap for Success

In healthcare operations and finance, establishing a robust Payment Integrity (PI) program is imperative for optimizing financial health and ensuring quality care delivery. However, embarking on this journey requires a clear roadmap and execution focus to navigate the complexities effectively. Drawing from insights learned from my article “Navigating the Landscape: 10 Lessons Learned while Implementing a Payment Integrity Office in Healthcare Operations,” In this article I aim to explore how crafting a comprehensive roadmap can pave the way for success in PI initiatives.

Mile marker

Developing a roadmap is the cornerstone of any successful PI endeavor. It serves as a guiding framework, outlining key milestones, objectives, and strategies to achieve desired outcomes. In my experience, aligning this roadmap with organizational goals and priorities is crucial to ensure its relevance and effectiveness.

One of the key decisions in crafting this roadmap is determining the optimal mix of internal capabilities and external vendor solutions. Leveraging both internal expertise and external resources can enhance efficiency and effectiveness in addressing payment integrity challenges. Moreover, this approach allows for flexibility, enabling organizations to bring vendor activity in-house over time as the PI organization becomes more established.

The components of a robust PI roadmap are diverse and encompass various capabilities aimed at identifying and mitigating payment inaccuracies, fraud, and waste. These components include:

  1. Coordination of Benefits (COB): Streamlining processes to ensure accurate coordination of benefits across multiple payers, reducing overpayments and inappropriate claim reimbursements.
  2. Payment Integrity Platform: Implementing a comprehensive platformto centralize data, streamline workflows, and enhance decision-making capabilities in identifying and resolving payment discrepancies.
  3. Data Mining: Harnessing advanced analytics and data mining techniques to uncover patterns, trends, and anomalies indicative of potential payment errors or fraudulent activities.
  4. Claims Editing: Implementing automated claims editing solutions to flag and correct inaccuracies, ensuring adherence to billing guidelines and regulatory requirements.
  5. Fraud & Abuse Program (SIU): Establishing a robust Fraud & Abuse program with a specialized investigative unit (SIU) to detect, investigate, and mitigate instances of fraudulent billing practices.
  6. Clinical Reviews: Conducting thorough clinical reviews to validate the medical necessity and appropriateness of billed services, minimizing overutilization and unnecessary healthcare expenditures.

By integrating these components into a cohesive PI strategy, organizations can enhance their ability to identify, prevent, and recover improper payments effectively. Moreover, a clear roadmap enables stakeholders to align efforts, allocate resources efficiently, and monitor progress towards achieving overarching PI goals.

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In conclusion, crafting a clear roadmap and execution focus is paramount in driving success in Payment Integrity initiatives within healthcare operations and finance. By developing a comprehensive roadmap that aligns with organizational objectives and leverages internal and external resources effectively, we can navigate the complexities of PI and optimize financial outcomes while ensuring quality care delivery.

Reach out to us to explore how we can support your organization’s Payment Integrity transformation!

VP of Healthcare Consulting at Curate Partners

Meet the Author

Chad Roswick, VP of Healthcare Consulting

Link to bio

The material and information contained in this resource is for general interest purposes only and is based on our experience; it does not constitute financial, legal, or investment advice.
02Apr
Overcome Data Challenges: Building a Strong Payment Integrity Program for Health Plans

Building a Strong Payment Integrity Program: Challenges and Solutions for Health Plans 

WEBINAR RECAP

Unraveling Payment Integrity Challenges: Tactics for Sustainable Success

recording of payment integrity webinar
Speakers:
  1. Chad Roswick, VP Healthcare Consulting, Curate Partners
  2. Dennis Rossi, Data & Analytics Solutions Partner, Curate Insights
  3. Emily O’Brien, VP Healthcare Solution, Curate Partners

Healthcare costs are a major concern, and health plans are constantly seeking ways to optimize their spending. Payment integrity (PI) programs play a crucial role in this effort by identifying and preventing improper payments. However, building a successful PI program can be challenging. This blog post dives into the key takeaways from our recent webinar on this topic, exploring the common hurdles health plans face and outlining best practices to overcome them.

1. Data: The Foundation and the Challenge

At the heart of any PI program lies data. Unfortunately, accessing the right data can be a significant obstacle. Data is often scattered across various systems, requiring close collaboration with IT to ensure its quality and completeness. Additionally, platform migrations can further disrupt data access for PI initiatives.

2. Data Analytics: The Engine that Drives Results

A robust PI program goes beyond simply having data. It requires a certain level of data analytics maturity within the organization. This involves having a dedicated data platform, robust data quality processes, and skilled personnel who can manage and analyze the information effectively.

3. Governance: Setting the Course for Success

For an in-sourced PI program to thrive, establishing a formal governance structure is essential. This typically involves an executive committee that provides strategic direction and allocates resources. Additionally, a working group with representatives from various departments is crucial for evaluating and approving new opportunities.

4. Internal Capabilities: Building a Scalable Solution

Many health plans have internally developed PI tools. While these tools may have served initial needs, they can often lack scalability and rely heavily on manual processes. Regularly evaluating internal processes and technology is crucial to ensure they can support the program’s growth and future needs.

5. The Future of Payment Integrity: Shifting to a Prepay Model

Traditionally, PI programs reviewed claims after payment (retroactive approach). However, there’s a growing focus on shifting to a prepayment model (proactive approach) to identify and prevent improper payments upfront. This can improve provider relationships by reducing claim denials later and streamline processes for both health plans and providers.

Beyond the Basics: Additional Tips for Success

The webinar also offered valuable insights beyond the core challenges:

  • Engage IT Early: Involving IT from the outset ensures a smoother implementation process and facilitates access to the necessary data.
  • Prioritize Independence: Avoid piggybacking PI initiatives onto other large programs. This can lead to resource allocation issues and hinder the effectiveness of both programs.
  • Collaboration is Key: Partnering with the business side is crucial for defining data quality standards. Clear communication and collaboration will ensure the program focuses on identifying and preventing the most impactful improper payments.

Building a strong PI program requires careful planning and ongoing evaluation. By addressing the challenges discussed above and implementing the suggested best practices, health plans can leverage PI programs to optimize their spending and ensure they are delivering the best possible value for their members.

View Full Webinar:


02Apr

Unlocking Payment Integrity Success: Why Claims Leaders Need Dedicated Support

Unlocking Payment Integrity Success:

Why Claims Leaders Need Dedicated Support

In my experience navigating the intricate world of healthcare operations and finance, I’ve come to recognize a crucial aspect that can make or break Payment Integrity (PI) initiatives: the need for dedicated support. Let me share why expecting claims leaders to manage PI efforts alongside their existing responsibilities can hinder progress rather than propel it forward.

As someone entrenched in healthcare operations, I understand the conflicting incentives claims leaders face when it comes to PI. Their objectives often revolve around reducing provider abrasion, improving auto-adjudication rates, and minimizing provider disputes. However, the implementation and management of incremental PI solutions demand a significant amount of time and resources, which claims leaders may not always have at their disposal. From my vantage point, it’s clear expecting claims leaders to juggle these competing priorities can lead to fragmented efforts and suboptimal outcomes. That’s why I firmly believe in the necessity of establishing a separate PI organization with a distinct focus and clear accountability.
Payment Integrity Success Vantage Point

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Payment Integrity Success CARVE

By carving out a dedicated team for PI initiatives, organizations can ensure these critical efforts receive the attention and resources they deserve. This approach allows for concentrated efforts on identifying and addressing payment inaccuracies, ultimately leading to improved financial outcomes and stronger relationships with providers.

Moreover, a dedicated PI organization fosters collaboration across departments, harnessing expertise from various stakeholders to drive meaningful results. With clearly defined goals and accountability structures in place, organizations can streamline processes, implement targeted interventions, and measure outcomes more effectively.

In conclusion, my journey in healthcare has taught me the importance of providing dedicated support for Payment Integrity initiatives. By establishing a separate PI team, organizations can accelerate their PI program, optimize financial health, and ensure quality care.

Let’s make Payment Integrity a strategic focus and commit the necessary resources and support to achieve success.

VP of Healthcare Consulting at Curate Partners

Meet the Author

Chad Roswick, VP of Healthcare Consulting

Link to bio

The material and information contained in this resource is for general interest purposes only and is based on our experience; it does not constitute financial, legal, or investment advice.
19Mar

Navigating Skepticism: Building Momentum for Payment Integrity in Healthcare Operations

Navigating Skepticism:

Building Momentum for Payment Integrity in Healthcare Operations

Embarking on the journey to establish a robust Payment Integrity (PI) program within healthcare operations often entails addressing initial skepticism and misconceptions. In my two decades in healthcare, I’ve encountered a spectrum of comments reflecting initial skepticism when introducing PI initiatives:
PI Mirco 2 think
  • “What is PI, and why do we need it?”
  • “We already have a quality department.”
  • “Providers are going to be frustrated because we’ve always paid it this way.”
  • “Why do we need another claims organization to monitor claims?”
  • “We can do PI with existing staff.”

These comments underscore the need for comprehensive education and advocacy surrounding the significance of Payment Integrity. Given these common concerns, I’ve championed initiatives to address these concerns, emphasizing the transformative potential of PI in a variety of health plans.

Navigating the path to Payment Integrity requires a multi-faceted approach. Identifying quick win opportunities and showcasing incremental savings are pivotal in gaining organizational buy-in. Additionally, by reviewing savings examples cross-functionally, stakeholders gain insights into actionable strategies for reducing medical expenses and enhancing financial outcomes.

Over the course of my career, I’ve observed that after approximately six months of implementation, a notable shift occurs within the organization. Skepticism gives way to curiosity, and eventually, to enthusiasm as stakeholders begin to recognize the tangible benefits of PI. This transformation marks the onset of momentum—a momentum driven by results and a deeper understanding of the value PI brings to the table.

It’s crucial to acknowledge that providers are accustomed to payment integrity audits from various payers, albeit possibly not from your specific plan. Transparent communication about the objectives and benefits of Payment Integrity fosters collaboration and trust-building with providers, ultimately enhancing the program’s effectiveness.

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In conclusion, my journey as an industry expert has taught me that overcoming skepticism and misconceptions surrounding Payment Integrity is an essential precursor to driving innovation and excellence in healthcare. By leveraging education, advocacy, and strategic initiatives, we can pave the way for sustained financial health and quality care delivery. As momentum builds, the focus shifts from questioning the need for Payment Integrity to maximizing its impact.

Elevate your organization’s Payment Integrity efforts with our guidance and support. Reach out today to discuss how we can collaborate to drive innovation and excellence in healthcare operations.

VP of Healthcare Consulting at Curate Partners

Meet the Author

Chad Roswick, VP of Healthcare Consulting

Link to bio

The material and information contained in this resource is for general interest purposes only and is based on our experience; it does not constitute financial, legal, or investment advice.
12Mar

Leading the Way: The Crucial Role of Executive Leadership in Payment Integrity 

Leading the Way:

The Crucial Role of Executive Leadership in Payment Integrity

In the complex landscape of healthcare operations, one principle stands out above all: Payment Integrity (PI) starts at the top. At the helm of every successful PI initiative lies the unwavering commitment and strategic vision of executive leadership. As highlighted in a recent article, “10 Lessons Learned While Implementing a Payment Integrity Office,” the journey towards PI excellence is paved with valuable insights and lessons. Here’s why executive buy-in is not just essential but indispensable in driving Payment Integrity within healthcare finance.

Payment Integrity Team Work

1. Developing an Effective PI Organization:

Executive leadership serves as the catalyst for developing a robust PI organization. Their guidance and direction are pivotal in shaping the ongoing structure, policies, and objectives necessary to ensure long term financial stewardship.

2. Fostering Collaboration Across the Organization:

Achieving Payment Integrity requires collaboration across various departments, including Operations, Network, Clinical, and Compliance. Executive leadership plays a crucial role in fostering this collaboration, ensuring that all cross-functional areas are engaged and aligned with the overarching goals of PI.

3. Embracing Provider Abrasion:

The journey towards Payment Integrity may entail some level of provider abrasion, especially in organizations establishing their programs. Executive leadership must have the appetite and courage to navigate these challenges, championing the cause of PI even in the face of resistance.

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4. Investing in Resources and Tools:

Implementing effective PI initiatives necessitates both internal and vendor investment. Executive leadership must recognize the importance of allocating resources to develop and deploy the necessary tools, processes, and technologies essential for success in Payment Integrity.

5. Recognizing Pre-Payment Savings:

Leadership’s ability to recognize the significance of pre-payment savings is paramount. By incentivizing the early detection and resolution of issues before claims are paid, executives can proactively safeguard the organization’s financial interests while promoting a culture of accountability and excellence.
Payment Integrity tools

Conclusion:​

In conclusion, executive leadership plays a pivotal role in driving Payment Integrity within healthcare operations and finance. Their vision, commitment, and strategic direction are indispensable in fostering collaboration, embracing challenges, and ultimately, ensuring the financial well-being and ongoing support of the organization.

Reach out today to learn how our expertise can support your organization’s journey towards financial integrity. 

VP of Healthcare Consulting at Curate Partners

Meet the Author

Chad Roswick, VP of Healthcare Consulting

Link to bio

The material and information contained in this resource is for general interest purposes only and is based on our experience; it does not constitute financial, legal, or investment advice.
25Jan

Navigating the Landscape: 10 Lessons Learned while Implementing a Payment Integrity Office in Healthcare Operations

Navigating the Landscape:

10 Lessons Learned while Implementing a Payment Integrity Office in Healthcare Operations

In the dynamic realm of healthcare operations, the successful implementation of a Payment Integrity Office is crucial for financial stability and operational efficiency. Navigating the payment integrity journey can prove challenging due to factors such as ever-changing regulatory requirements, data integration issues, the dynamic healthcare landscape, contractual variability, and the added complexity of evaluating multiple vendor solutions. However, incorporating these key lessons learned can effectively position your organization for success. Drawing from over two decades of experience, I‘ve identified ten valuable lessons that healthcare professionals involved in payment integrity should consider. Let’s explore these insights, which can act as a roadmap for individuals leading their organizations toward a strong and efficient payment integrity program. 

1. Payment Integrity Starts at the Top​:

Initiating payment integrity efforts requires leadership commitment. Without support from top executives, the implementation process can face several avoidable obstacles. Leaders must champion the cause and communicate its significance throughout the organization.

2. Building a Culture of Payment Integrity:

Beyond mere implementation, cultivating a culture that values payment integrity is essential. This involves aligning organizational values, fostering accountability, and promoting a collective commitment to accuracy and compliance across the organization. 

3. Avoid Having Claims Leaders Support Payment Integrity ‘Off-the-Side of their Desk’:​

Building payment integrity isn’t a sideline project. Claims leaders have conflicting priorities which make it difficult to focus on building and expanding payment integrity programs. It is imperative to have dedicated resources accountable for the success of the program.

4. Crafting a Clear Roadmap and Execution Focus: ​

Developing a comprehensive roadmap is the foundation. However, equal emphasis must be placed on execution. A well-defined plan, coupled with a proactive approach to addressing challenges, is key to successful payment integrity implementation. 

5. Accelerate with Expertise: ​

Having experienced professionals in payment integrity on your team can significantly accelerate the program. These seasoned individuals bring a wealth of knowledge that can significantly accelerate the program’s progress. While leveraging vendor solutions is crucial for expanding your payment integrity organization, internal resources play a pivotal role in advocating for the health plan’s interests. 

6. Measure Results and Pilot Programs: ​

Regularly measuring and evaluating results is fundamental. Piloting programs not only aids in fine-tuning strategies but also gains organizational support by showcasing tangible benefits. 

7. Evaluate Provider Contracts: ​

Don’t assume provider contracts inherently support payment integrity objectives and/or actions. Actively evaluate contracts and make necessary modifications, including retraction language and coordination of benefits clauses, to align them with payment integrity goals. 

8. Authorized Services ≠ Guaranteed Payment: ​

Understanding that authorized services don’t guarantee payment is critical. Assess authorization language to confirm alignment with payment integrity objectives.  

9. Develop a Cadence for Stakeholder Engagement: ​

Establishing a regular cadence with key stakeholders is imperative. Regular cross-functional reviews and approvals of payment integrity savings opportunities creates a sense of involvement and ‘buy-in’ across the organization, fostering a collaborative environment. 

10. Enhance Provider Communication: ​

Recognize the critical role of provider communication in the payment integrity process. Continuous improvement in communication strategies will enhance understanding, cooperation, and overall success. 

Conclusion:​

Curate Partners’ comprehensive payment integrity program implementation offerings are designed to elevate your operational efficiency journey. We guide you from decision to deployment; offering a fully vetted implementation methodology for every step, a wholistic understanding of cross-functional implications, access to high-demand talent, and a rapid deployment infrastructure. Curate Partners ensures your organizational and operational PI structure is assessed and improved during the earliest program planning stages, fostering a sustainable and profitable payment integrity mindset. 

If you’re looking to implement a sustainable, profitable payment integrity mindset, feel free to reach out to us to explore how we can support your endeavors. 

VP of Healthcare Consulting at Curate Partners

Meet the Author

Chad Roswick, VP of Healthcare Consulting

Link to bio

The material and information contained in this resource is for general interest purposes only and is based on our experience; it does not constitute financial, legal, or investment advice.