Unraveling Payment Integrity Challenges: Tactics for Sustainable Success

  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.

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Initiation, Strategic Vision & CX - HCD