Kaitlin Howard

By Kaitlin Howard

Kaitlin Howard is a researcher and writer producing insightful content across the healthcare revenue cycle. She has written and produced content for Zelis, Waystar, and Recondo Technology, as well as agencies. With a B.A. in English and Writing from University of Denver, Kaitlin stays current on market updates on claims management and healthcare payments, publishing a regular educational blog series on industry trends and Zelis offerings.

Payment integrity is more than just a major component of cost containment. It’s also a strategic asset.

But there are two distinct sides to payment integrity.

Typically, providers are focused on maximizing revenue. And they do this by hiring billing firms to identify areas of opportunity for revenue maximization.

Payers, on the other hand, tend to place more stress on controlling improper payments. But are often not equipped to handle the associated complexities, especially with their current disparate and outdated systems.

Many health plans are starting to recognize this. And their first course of action is often to consolidate under a centralized payment integrity function.

The can of worms

A recent report completed by the U.S. Department of Health and Human Services (HHS) discovered that many private Medicare plans routinely rejected claims that should have been paid and denied medically necessary services.

In fact, due to claim processing errors, private Medicare plans actually denied 18% of all claims.

That’s just the tip of the iceberg.

Once payers start looking into their current processes and technologies, the cracks really begin to show. Some typical gaps include:

  • Lacking communication with third-party vendors
  • Limited IT analytics and resources
  • Internal silos
  • Outdated disparate systems

And for many payers, these gaps can seem nearly impossible to remedy without the right payment integrity infrastructure to streamline, balance, and clarify the payment process.

Enter, third-party vendor partners

Payers have options when it comes to facilitating greater payment integrity efficiency. One of which is to utilize multiple vendor partners or streamline to one comprehensive partner. But more doesn’t mean better for everyone. In fact, an increase in solutions increases the potential for technological breakdowns and data disconnects along the way.

That’s why it’s so important to find the right partner and right solution for your organization.

To help, we’ve developed the 5 Cs of Payment Integrity as a way to ensure you’re getting the most out of your vendor partner.

But what else should a payer be looking for?

1. Try a single vendor approach.

Ultimately, the more vendors you have, the more work it creates for IT and operational staff. If you can consolidate your payment integrity services to a limited number of vendors, your operations will become much more streamlined.

By addressing the most abrasive aspects of the payments process, you purposefully evolve your existing process to reduce friction between payers and providers, bringing both stability and predictability to reimbursement.

2. Invest in comprehensive solutions.

You need comprehensive, enterprise-wide solutions that cover all of payment integrity.

Meaning: you need a 360-degree solution that seamlessly integrates into your current workflows to prevent further gaps.

The wrap up

As more regulations come into play and members become more financially savvy, transparency in healthcare is critical. Yet oftentimes, there is a black box around vendor partner solutions and within current workflows that prevent you from truly knowing what’s going on and why.

When you look at your internal processes and partners, ask yourself:

  • Do I know how workflow decisions are made? How is the logic built?
  • Why are claims recommended for further review? Why are they recommended for payment? Is there an underlying pattern?
  • What happens during the claim review process? Are there any gaps?

To learn more about other best practices within the payment integrity market, check out our latest blog.

To get started with a Zelis approach to payment integrity, connect with us.