With the right partner and a technology-driven approach to claims review, payers can elevate their payment integrity strategy to do much more than fraud, waste, and abuse prevention. A comprehensive payment integrity strategy is key to lowering costs and providing the streamlined experience providers and members deserve.
“The real goal of payment integrity is to free up money for improvements that impact patient care,” says Timothy Garrett, MD, Chief Medical Officer, CCS, at Zelis.
Blues plans can strengthen their reputation for providing an integrated and affordable healthcare experience with a payment integrity strategy built with the entire healthcare landscape in mind.
5 Key Features of a Comprehensive Payment Integrity Strategy
1. Reduces financial leakage
The industry currently wastes $265.6 billion on administrative complexity and between $230.7 billion and $240.5 billion on pricing failures annually.
A comprehensive payment integrity solution can streamline claims management processes to reduce administrative costs through prevention of improper and incorrect payments before they reach providers. Analytics and pre-payment claim reviews can also ensure services are medically necessary for members.
2. Aligns with member expectations
Addressing member needs is a top priority for any Blues plan. Members want an integrated, affordable health plan that provides a seamless experience. Additionally, members are interested in more convenient access to their coverage and pricing information.
“If the COVID-19 pandemic has taught us anything, it’s that access to healthcare and its associated costs are of vital importance to everybody,” Garrett explains. “Payers are uniquely situated to impact healthcare costs in a way that is beneficial to us as individuals.”
Providing transparency and lower costs is necessary for payers.
3. Addresses administrative complexity
The administrative side of healthcare is extremely complex. Providers are tasked with overseeing and navigating various reimbursement models and contracts with each of their payer partners. This complexity often leads to confusion, challenges in managing updates, and adds to the operational stress experienced by both providers and their billing departments.
Payment integrity reduces that friction to streamline claims management and get accurate reimbursement quicker.
“Payment integrity levels the playing field for payers and providers,” Garrett states. “It makes sure that everyone is operating within the rules laid out in regulations and policies as well as clinical guidelines and definitions.”
4. Maintains compliance with changing rules
Staying ahead of the legislative curve is critical for payers. It often includes keeping current with changing ICD-10 and CPT codes, which is a challenge due to annual updates and ongoing releases. Yet managing these codes effectively is crucial, as new, updated, or sunset codes can impact prompt-pay guidelines.
This is where having a partner with expertise in healthcare legislation comes in. Partnering with a vendor who monitors these changes can strengthen operations and provider communications, enhancing transparency and preventing future issues.
5. Alleviates workforce challenges
A potential aging crisis has implications for payers as the Boomer generation begins to leave the workforce. One in five adults in the U.S. is over the age of 65, presenting a dramatic increase in risk pools as people retire.
The importance of payment integrity is very clear. “You need to make sure that payments are accurate because changes in risk pools can lead to an increased chance that you could overspend in some areas, and that leaves less resources to help elsewhere,” Garrett explains.
Internally, payers may find gaps in their workforce. According to the AMA, there is a 30% shortage in medical coders, meaning finding qualified applicants for roles in this area can be a challenge, or an unexpected expense.
Payers will have to rely on technology and expert coders to ensure payment integrity in the current economy. Adding automation can also enable payers to allow remote work in a secure, seamless fashion, making their plan more attractive to job candidates.
A good vendor partner will be able to recognize the unique challenges payers face and tailor solutions and services that fit the organization’s needs.
Finding the Right Payment Integrity Partner
“Not being able to find expertise to do payment integrity work internally makes partnering with vendors even more important,” Garrett states. “And the key word is ‘partnering.’”
The best fit is a payment integrity partner that understands how to increase value across the healthcare continuum and provides more support than just managing costs. This approach not only meets immediate business needs but can also strategically position Blues plans for long-term success.
When choosing a payment integrity partner, consider the importance of a partner that provides in-depth reviews by healthcare experts, addresses high-risk claims, reduces financial leakage, and monitors evolving requirements and provider billing trends.
Fueling Blues success with innovative payment integrity solutions
Zelis is increasing claims savings for Blues by addressing the claims, pricing and payment needs of members and providers.
1. Expert Claims Review: Precision in Every Process
Maximize your claims processing efficiency with Zelis Expert Claims Review®, where healthcare experts deliver meticulous pre- and post-payment reviews aligned with Association mandates. Our service integrates seamlessly with your existing systems, reducing IT complexity and enhancing operational efficiency through advanced DRG coding and detailed medical record reviews. Benefit from intelligent claims routing technology that identifies high-risk claims, ensuring accuracy and timeliness. Expert Claims Review is a solution where technology and expertise converge to save you time, resources, and reduce provider abrasion.
2. Secondary Editing: Enhanced Savings
Get a customizable, full-service solution for enhancing claims accuracy and savings, tailored specifically to your Blues plan’s requirements. Our expert team supports you from implementation through ongoing management, using advanced technology to quickly identify and correct coding errors. This efficient and personalized approach ensures compliance with Association mandates and accelerates financial benefits, allowing you to concentrate on core priorities—your members.
Learn More by visiting our Payment Integrity page or Contact Us.