Health Plans Return to Payment Integrity
3 claims trends associated with the healthcare industry getting back to business, and how health plans can smoothly resume payment integrity efforts.
Now that the crisis-volume of COVID-19 cases has started to ease across the country, delayed elective procedures and in-person provider visits are beginning to resume. While providers return to some semblance of normalcy, health plans are returning to business as usual as well. Our health plan clients are making moves to resume retrospective payment integrity audits they paused in order to relieve the provider administrative burden. What does “back to normal” look like for the healthcare industry, and how can health plans do a health check on the lingering symptoms of the pandemic to ensure their return to cost containment operations goes smoothly?
The “Great Pause” Brings Clarity for Health Plans
While providers have borne the brunt of the pandemic, health plans appear to have weathered the first months of COVID-19 relatively unscathed – or have they? Even in the short-term, there have been significant changes for health plans. Changes such as receiving more telehealth claims than ever before, heightened data security challenges, and facing rapid upheaval of processes in an already administratively complex environment. What’s more, they have risen to the occasion to support their network providers and members, who have suffered significant hardships during this time.
In addition, with the dramatic reduction in healthcare encounters, overall claim volumes have dropped as well, especially for those insurers whose populations reside outside of virus hotspots. Taken alongside pledges to accelerate payments to providers and reduce their administrative burden by minimizing claims recovery efforts to only the most egregious cases, this situation has left payment integrity departments with more breathing room in their day-to-day than usual. And it couldn’t come at a better time.
During periods of great uncertainty like the industry is experiencing now, the most critical skill is adaptability: being able to focus on surviving in the current moment while also building toward thriving in a future that will look different. Increasingly for health plans, innovations to survive in the short-term and thrive long-term look like technology – including both novel uses for existing tools and new solutions to address new (and old) challenges.
These were trends before the coronavirus pandemic, and the urgency of the situation has only magnified technology’s importance in supporting members, offering work environment flexibility and reinforcing relationships with providers. As the chief medical officer at one large regional health plan explains, “We need to be more open to change, step out of our comfort zones and embrace the unfamiliar. Barriers that have stymied innovation in healthcare aren’t as insurmountable as we once thought.”
Increased Healthcare Utilization Results in 3 Claims Trends
Now that health plans have navigated through the short-term impacts and are putting plans in place to position for long-term success, they are better prepared to adjust to the new normal of healthcare. A recent survey indicated that 80% of payer respondents expect a sharp increase in claims over the next few months. For payment integrity departments, that signals a return to processing claims as before, even as some changes in healthcare utilization are expected to continue for a while. Here are 3 claims trends health plans can look out for in the next phase of reopening.
1. Resumed elective procedures, ER and outpatient visits
In addition, emergency department use and physician visits best conducted in-person are also rebounding. ER visits, which dropped 42% during April, have recovered 21-32% of volume, depending on patient age. Outpatient volumes recovered over 50%.
As procedures and face-to-face encounters resume there is a concern that the delay may have caused conditions to worsen, resulting in more complex and costly claims. In one survey, “more than one in ten of those who skipped care reported that their condition declined because of their decision to postpone care.”
2. Continued telehealth, home health claims
For the rest of patients whose maladies can be managed and addressed remotely, telehealth and other modes of virtual care are still a popular option. Its use increased more than 4,000% over the last year, growing from 0.17% of medical claim lines to 7.52%. Now that consumers – and their providers – have been prompted to try it, they have found telehealth lives up to its promise of convenience, without unduly limiting the effectiveness or person-to-person connection of the visit. It also comes at a lower cost, and a new report estimates at least 20% of care could be offered digitally.
Home health, too, has found its moment for patients who, for instance, regularly receive infusion treatments, need dialysis or require post-operative care. These trends have accelerated due to advances in at-home technology along with payers temporarily relaxing restrictions. However, whether these prove to be temporary changes or a permanent shift remains to be seen.
3. Increased behavioral health utilization
The stresses of living during a global pandemic, along with increased social isolation due to stay-at-home orders, have negatively impacted mental health conditions for many Americans. Prescriptions for antidepressants, anti-anxiety and insomnia medications spiked in the first months, many for first-time use. At the same time, while inpatient mental healthcare capacity and utilization has dropped, many patients have taken advantage of virtual mental health visits.
One technology vendor executive attributes this increase to reduced stigma associated with telehealth, along with greater availability. That is a hopeful sign for wellness initiatives, and because counseling is one of the specialties more readily covered by telehealth even before the pandemic, this trend may continue indefinitely.
How Health Plans Can Improve Payment Integrity Agility
With the understanding that healthcare may be in flux until a reliable vaccine and/or treatment for COVID-19 is available, health plans are returning to their claims recovery efforts with sensitivity to how this activity affects providers and members. This transition requires agility, which is a cultural initiative and skill. As a leader at a large state-based health plan says, “We put these skills into action during the COVID-19 pandemic, making decisions rapidly to respond to the needs of our members and providers.”
Responding to member and provider needs with tech innovations
Adjusting to the rapid changes in healthcare to be responsive to member and provider needs may start with a culture shift, but technology is the enabler. Providers and members both are still reeling from the coronavirus impact, and health plans are best positioned with real-time data to promote seamless communication and continue the shift to prepay.
Real-time data provides the insights needed to determine how and when to adjust the response. Health plans can leverage an integrative platform like Pareo to ingest data feeds from multiple sources for a fuller view of the claims environment. It’s a first step towards interoperability, which supports both members and providers.
Seamless digital communication follows. At some point, health plans will begin to roll back the financial relief they have been extending to members and providers. The waived copays and cost sharing for coronavirus testing and treatment. The relaxation of prior authorization requirements. To ensure members and providers don’t end up holding the bag due to lack of knowledge, seamless two-way digital communication is key. Both internally with payment integrity departments and externally with members and providers.
Pareo Provider includes a web-based portal designed to engage with providers on claims status, education, medical records exchange, data sharing and other relevant two-way communication to foster this valuable partnership. Request a Sell Sheet
Prepay claims processing has come into its own during the healthcare crisis to reduce abrasion with providers. It’s more sustainable than accelerating payments and CARES funds, which have many strings attached, and reduces the costs associated with reworking claims – for both payers and providers. While post-pay payment integrity audits will never cease entirely (combating healthcare fraud, in particular, is largely a post-pay activity), minimizing the administrative burden of “coming from behind” to adjust payments in favor of more prepay work is a trend that’s here to stay.
Pareo Prepay supports this shift from pay-and-chase to working claims before payment with a concepts repository accessible across the payment continuum and configurable workflows that easily accommodate tight prepay timelines. Request a Sell Sheet
The Bigger Picture
Innovations in payment integrity have long been a goal at health plans. Health plans that we speak with continue to drive home the importance of data at this crucial time, to provide a measure of predictability during a situation that’s far from certain. Yet, connecting data from disparate streams and collapsing it into usable insights – insights which can be drilled down into – is still far from available to many health plans.
Imagine a platform in which your entire payment integrity operations are fluid, accessible, operational – in real time. Imagine accessing configurable reporting that offers actionable insights, tracks KPIs, and connects previously disparate data streams.
Advanced technology platforms like Pareo put this goal within reach for more payers – not just those with vast resources at their disposal. Pareo now more than ever has the chance to revolutionize the healthcare industry. Are you ready to learn more?
Now’s the time for total payment integrity
See the ClarisHealth 360-degree solution for total payment integrity in action.