25Jan

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 programsIt 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.