Thoughts on Creating a Centralized Payment Integrity Department

Does it make sense for your health plan to carve out Payment Integrity from your other cost containment efforts into a dedicated department with greater oversight capabilities?

Historically, payment integrity efforts have been scattered among specialty departments dedicated to different areas of cost containment. While it may have made sense at one time to have each department handle its own payment integrity efforts, does it now? Lately we’ve noticed a trend among strategically-minded health plans of creating a centralized payment integrity department.

Maybe this is news to you, or perhaps your health plan has adopted such a structure. Either way, this article explores the key to creating a centralized payment integrity department: comprehensive technology. Without a uniting platform, centralizing your payment integrity efforts will only be surface-deep.

A Strategic Imperative

Why are payment integrity departments centralizing their efforts? Most likely because it aligns with other necessary changes in healthcare, including the elimination of data silos and designating a single point of accountability. It may be an answer to the organizational challenges that put payment integrity in peril at organizations. “Our nation’s claims payment system is highly complicated…over time, this has resulted in the growth of numerous groups to address such issues,” writes Healthcare Finance.

These groups include subrogation, coordination of benefits, overpayments, SIU/FWA, and more. In the past, the issue hasn’t been that a health plan doesn’t understand the business case for payment integrity, notes Healthcare Finance. It’s simply just been too complicated to coordinate. It’s estimated that by centralizing PI efforts however, returns on claim spend can increase 10x.

Centralizing your PI department is a strategic imperative as health plans are being asked to engage at a higher level with their data and to essentially do more with less. But, how? How can a health plan keep specialty departments in play while carefully gleaning PI-specific tasks out into one central department? It’s an incredibly complex issue, so how are health plans making centralization work? The answer it seems is technology.

Change Management Techniques

As you likely know, just because centralizing payment integrity efforts sounds good on paper doesn’t mean it is easy. Moving responsibilities away from singular departments may be hard for organizations used to interdepartmental autonomy. How can you motivate acceptance of change?

“Based on interviews with officials from agencies, we found that visibility and accountability are motivating,” writes the authors of this MITRE report titled “Payment Integrity: What Motivates Entities Making Payments and Claimants to Optimize Ongoing Payment Integrity Efforts?” The report makes 11 recommendations for system transformation. Those recommendations are summarized below:

1. Set clear organizational goals with accountability
2. Establish a culture of Payment Integrity
3. Balance closely priorities of “mission” and “management”
4. Emphasize coordination to address challenges
5. Address statutory barriers
6. Explore funding options to strengthen PI
7. Consider PI when modernizing technology and shared service systems
8. Give claimants easy ways to interact with agencies
9. Be proactive and timely when communicating with claimants
10. Broaden use of data-mining and other “compliance-oriented motivators”
11. Expand compliance motivators as needed

While aimed at OMB and agencies, the above recommendations can be emulated by health plans as they centralize PI efforts as a way to more strategically align with regulatory agencies. Furthermore, as we distill these regulations in to actionable insights, it seems helpful to note that change management techniques (when combined with comprehensive technology) can assist in the development of a PI department.

When it comes to obtaining widespread acceptance, “the goal is to change their perspectives on the solution,” writes Kate Nimety, Senior Director at Zuri Group. For change management to truly occur and be effective, your organization will have to focus on vision and build a message (vision). The message you send to staff can empower them to accept new processes and mentalities. If it is understood that technology and a different way of doing things makes things better, change is much easier to accept.

Outsourcing Solutions

Health plans may not realize that totally outsourcing the function of their payment integrity department is an option. Pareo® can step in where others leave off, allowing your health plan to have complete operational transparency without a heavy lift. Gain traction, quickly, and rely on the processes that Pareo® helps you build alongside your Payment Integrity department so you can one day insource the work completely.