$4.1T (or $12,530 per person) was spent in the United States on healthcare in 2020. That’s a 9.7% increase from 2019.
The National Heath Care Anti-Fraud Association estimates that health care fraud costs the nation about $68 billion annually.
As a healthcare payer, you must ensure provider claims are processed efficiently and paid accurately. Effective payment integrity can help. A streamlined payment process reduces friction between payers and providers, bringing reimbursement stability and predictability.
And the good thing is, you have options.
Payers can elevate their payment integrity strategy to do much more than fraud, waste, and abuse prevention.
“The real goal of payment integrity is to free up money for improvements that impact patient care,” states Dr. Timothy Garrett, MD, Zelis Chief Medical Officer, CCS.
The approach
Payment integrity approaches vary widely among insurers, and the success (or failure) of these programs significantly impacts operational capabilities and cost. Luckily, payers can facilitate greater efficiency in their payment integrity efforts by choosing a single strategic partner and data stream.
In a best-of-breed model, payers look to adopt a solution from an industry leader for each part of the healthcare payment process.
While this may seem like a viable option (who wouldn’t want the best of all worlds), oftentimes, what’s forgotten is cost. And by that we mean both the financial cost and the cost in terms of effectiveness. Think: staff hours required to manage non-integrated systems.
Alternatively, choosing a single vendor enables a streamlined one-stop shop. For payers interested in benefits design and care management, this is a particularly attractive option.
The why
“A single vendor approach is often the best choice because it allows a payer’s internal teams to direct their focus to strategic areas,” suggests Dr. Garrett. “Of course, some payers, especially large organizations, may have more needs than a single vendor can supply, but minimizing the number of vendors is of tremendous value in streamlining operations.”
A multitude of technologies creates the illusion of choice, but one of the key issues with bolt-on technologies is integration. Meaning: you’ll have gaps along your claims review and payments processes that hinder critical information flow.
Staff then carry the burden of processing the non-standardized data. And, let’s be honest, there’s just not enough time in a day.
A single vendor approach allows you to access correct content within your current workflows, enabling staff to get to the right work faster. Choosing the single vendor approach also allows you to have a go-to person to simplify troubleshooting and answer questions in real-time.
Another, perhaps not so obvious, benefit of the single vendor approach comes in the form of a more streamlined initial implementation.
The choice
It all boils down to asking questions.
Evaluate your potential vendors based on their ability to serve as a partner, not just the potential of their solution.
Dr. Garrett recommends that “payers ensure their potential vendor updates their content regularly, remaining in tune with the payer’s needs.” To do this, however, you need “open, honest, and transparent communication between the two.”
A good vendor can help you identify areas of strength within your organization, optimizing your outsourcing. Sometimes it’s more cost-effective to keep things internal, but you may not be getting the results you want. Your vendor should help you close those gaps.
Another key question focuses on vendor operations.
If your vendor is nationwide, they have the ability to not only identify solutions for a specific payer but also across the board. Hello, network effect.
Here’s some context in case you’re not familiar:
In economics, “network effect” refers to the value a user (aka you) derives from a solution depending on the number of others (aka other payers) using the same solution.
In other words, you gain more value the more other organizations use the same solution.
The wrap up
It’s time to streamline, balance, and clarify your payment processes.
Maybe you lack the right payment integrity infrastructure. Or maybe your resource utilization is lacking. Regardless, you need a partner whose goal is not only to build stronger connections between you, your providers, and your members but also to create the technology ensuring that goal.
To guide your payment integrity vendor search, explore the 5Cs of payment integrity here.