Where does your health plan reside on the payment integrity continuum?

Take this interactive self-assessment to determine how much progress your health plan has made towards modern digital transformation.

The goal for every future-looking health plan is to transition payment integrity efforts from predominantly external post-pay, to a healthy mix of prepay and post-pay both internally and externally. The current status for many health plans is highly reactive in nature, heavily dependent on external vendors, and losing $0.25 on every dollar recovered post-pay as a result. Strategic directors of payment integrity understand the potential of digital transformation: a greater focus on prepay functions yields a better balance between internal and external functions and improves recovery returns.

The Payment Integrity Continuum

As health plans evolve to effectively manage payment integrity, efforts to manage it become two-prong: centralize and shift. Plans further along in the evolution of payment integrity  realize that PI is a comprehensive activity. Breaking down data silos to centralize efforts is the first phase. Next, PI efforts shift to strategic, more proactive functions within the health plan. 

Self-Assessment: Where does your health plan fall on the PI Continuum?

Take this self-assessment tool to look strategically at key elements of your payment integrity activity and evaluate where your health plan falls along the PI continuum.  

Your Results: Steps Along the Continuum

All payment integrity efforts wrap around the specific needs of a health plan. But certain core functions exist and, in our experience, evolve over time to form a PI continuum that aims for integrative, comprehensive functionality within a health plan. Add up your points from your answers above, and let’s see how much progress your health plan has made and what your organization can do next to keep progressing.

Score Total Less than 7: Needs improvement

At this stage, we usually see a health plan with claim edits build into an adjudication system but limited post-pay identification efforts. Next steps:

1. You probably aren’t where you want to be regarding the latest technology, and that’s okay. Start small and strategically work your way towards catching up to your goals.
2. If you haven’t yet, consider adding a first-pass third-party service vendor to your payment integrity efforts. Here are some tips for choosing the right supplier partners.

Score Total 7 – 9: Making progress, slowly

With expanded post-pay activity covered by first-pass, third-party vendors for major services (COB, data mining, clinical audit) complementing internal post-pay efforts, you’re moving in the right direction. Next steps: 

1. Time to level up your efforts to combat fraud, waste and abuse. Start here.
2. Advanced technology will help you reach the next level of payment integrity, quicker, but it can feel disorienting to update your existing processes. Here’s our guide to making those internal discussions more fruitful.

Score Total 10-12: Headed in the right direction

By expanding post-pay activity with additional vendors, leveraging vendors as R&D to expand internal post-pay efforts to optimize spend, and introducing FWA technology, you’ve already made a lot of progress. But, you still have too many systems to manage in PI and know there’s more to be done. Next steps:

1. Ensure you’re making the most of your payment integrity vendor relationships.
2. If your organization’s PI efforts are spread across multiple departments and stakeholders (a common situation), you can address that structurally by creating a centralized payment integrity department.
3. Progress of this level can be uncomfortable. As an agent of change, you can help lead your organization into the future. 

Score Total 13-15: Gaining on it, but there’s still room to improve

At this level, you’re probably starting to feel pretty comfortable, introducing a third-party post-adjudication prepay vendor to complement post-pay and FWA efforts and reducing the number of disparate solutions you use to manage payment integrity. Next steps:

1. Make your first moves to transition claims recovery to prepay.
2. As your organization increases in sophistication, an integrated advanced technology solution will support those efforts — but only if it’s successfully adopted by key stakeholders.

Score Total 16-18: Your PI approach is close to being proactive

Almost there! By expanding post-adjudication prepay with internal prepay operations in advance of third-party solutions and continuing to round out post-pay activity, your digital transformation is almost complete. Next steps:

1. Are you missing any opportunities to maximize your recoveries?
2. Freely and securely exchanging data with services vendors, providers and best-in-breed technology solutions will secure your competitive advantage.

Score Total 19+: You’ve achieved a strategic, proactive PI management solution

Congratulations! At this level, you have all lines of business addressed pre- and post-pay with solutions in place to continuously evaluate and move post-pay identifications internally and ultimately to avoidance. As a result, you’re cost avoiding in excess of 30% of overall plan savings. 

Bottom Line

Wish your health plan was scoring a little higher on this assessment? Moving your health plan further along the payment integrity continuum with existing resources and processes is almost impossible. You aren’t alone and help is available. 

As one of our clients put it, “Our vision for payment integrity is to move from a predominant outsource to a predominant insource business model. It is a bold strategy, and we needed an equally bold and innovative partner. We explored many options, including an internal build, until we were introduced to ClarisHealth and Pareo. After the first demonstration of Pareo, we knew that it had tremendous potential to serve as the foundational payment integrity hub to realize our vision.”