While no two health plans are the same, the concern I hear most often is about the need to control both administrative and medical expenses while improving quality. Even today, there are still too many claims payment situations that require expensive manual intervention or where policies simply can’t be administered in the claims system.
Here’s an example. A group of providers might bill multiple preventive health visits per member per year, instead of evaluation and management patient visits. How long would it take to detect the aberrant billing pattern of this group of providers? Imagine the scope of work required to first identify the nature and extent of problem and then come up with a solution to close the gap:
- First, you would need to know where to begin looking in order to detect this pattern.
- Then, you would need to get access to the right historical data, know the right questions to ask and perhaps write a program to show a problem might exist — and then manually analyze the claims data.
- Next, you would have to put together a team to research these providers, gather and audit medical records, show evidence of abuse/waste and turn over this information to the area responsible for recovering unwarranted payments.
- Finally, you would have to configure and apply complex adjudication rules to identify the number of well patient visits per patient per year based on your payment policies, to prevent this problem in the future.
To fix this problem, several departments have to work collaboratively, including claims payment, investigations and network management. When these areas are out of synch your staff is doing a lot of expensive, time-consuming manual tasks and expensive rework. Simply put, you have an opportunity to control expenses, but to fix it will take weeks or months.
A better solution comes from automating processes and connecting information; for example: automating the encoding of contract terms for use in your claims payment process, and automating pattern recognition across claims. Together, these will enable you to close the gaps and ensure that you are paying accurately and appropriately and according to your payment policy — not to mention eliminating manual, inconsistent processes.
If you have the right tools today you can easily address the problem. For instance, you can use analytics to detect anomalies, update contract terms so they synchronize with your payment policy and create a rule to flag claims with a preventive health code submitted by a specific provider group.
This is what I mean by “payment policy optimization,” closing the gaps between contracting and claims payment, between claims payment and the investigation team, between the investigation team and contracting, so that all work together in a coherent cycle. Payment policy optimization is an opportunity that few organizations have recognized, yet it is capable of returning desperately-needed dollars to productive use in the healthcare system.
