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Enterprise Approach to Payment Integrity Technology: Using a Payment Integrity Maturity Model

By John Bair, CTO, LaunchPoint

John Bair, CTO, LaunchPoint

Health plans are realizing the tremendous value of looking at claims payment integrity from an enterprise perspective. The benefits of an enterprise approach are abundant as plans are under growing pressure to better manage margins to support the bottom line and meet the medical loss ratio. When considering the amounts of dollars spent on managing numerous recovery vendors and ensuring accurate claims management, payment integrity (or cost containment) functions are increasingly recognized as a source for adding value to the bottom line.

"A maturity model can be a valuable first step to help you map out technology goals and investments"

But many payment integrity groups struggle with manual processes, multiple sources of data with limited data integration capabilities, manual consolidation of reports, and inconsistent data. This may suffice as a developing payment integrity organization builds out its processes, grows a skilled team, and learns dependencies on other organizations, such as enrollment, claims, and finance. But in order for payment integrity organizations to mature and maximize recovery and cost avoidance results, they will need technology that enables repeatable workflows, data sharing, data integration, transparency, and reporting.

This is where evaluating your payment integrity efforts against a “Technology Maturity Model for Payment Integrity” will pay off by presenting next steps in the payment integrity transformation. A maturity model, such as the one shown below, can be a valuable first step to help you map out technology goals and investments.

When you take an honest look across your organization, you will start to identify where your organization falls along the maturity model. And keep in mind that there is no wrong level – whatever your departmental target for technologies and data is, there will be steps and improvements mapped out to advance your organization along the path to enterprise payment integrity success. Where do you think you fall?

• Stage One: Chaos

In the “chaos” stage of our technology and data maturity model, plans are still managing many processes such as subrogation, COB, DRG, claims review, and others in a very ad hoc, heavily manual manner. Data is completely siloed across departments with no transparency; data quality is typically poor. Workflows are minimally established and overall payment integrity results are inconsistent.

• Stage Two: Repeatable

As plans begin to improve cost containment and payment integrity efforts, they start to establish repeatable processes that combine manual and some automated methods. This increased automation provides more reliable and consistent results for users. Technology competencies are improving and users and beneficiaries of better reporting and results are expecting more.

• Stage Three: Defined

This stage is characterized by many plans as the stage where standardized operating procedures exist across major processes and visibility across these processes is enabled. Automated data exchange with partners (such as recovery vendors, CMS, state agencies, etc.) exists and data integration among departments is established. Reporting metrics are improving and providing more insight into the orga-nization.

• Stage Four: Managed

Data and metrics are now consistent across time and organizational perspectives and analytics are providing deeper insights into outcomes and other factors. The organization has more visibility into internal and external processes and pipelines. Users are able to take a “self-service” approach to their payment integrity dashboard and pull data and analytics to support organizational goals. We are reaching the apex of an enterprise level payment integrity model.

• Stage Five: Optimizing

This final stage is an ongoing process where technologies are maximized, data is transparent across the organization, workflows are automated and configurable and systems are managing multiple vendor services and providing analytics and performance metrics. And now that data is centrally administered and accessible throughout the organization in near real-time, payment integrity is assuring claims are being paid properly each time.

By identifying the stage of your current payment integrity and cost containment technology and processes, you will be able to better determine the best and most effective path for increased efficiencies and results–sometimes to the tune of millions of dollars. And remember, you aren’t alone. For many plans, technology and data management have often been neglected in favor of higher IT priorities. But those who move to an enterprise payment integrity model sooner than later will realize great advancements including improved eligibility data, increased ability to identify and pursue recovery opportunities, automated workflow processes and reports, and automated integration of multiple data sources.

For example, we worked with a leading Blues plan to identify enterprise wide strategies and programs to improve payment integrity recovery and cost avoidance from 1.4 percent ($80 million) to 2.0 percent ($120 million). Those types of numbers are hard to ignore, but measuring yourself against a payment integrity maturity model is just the first step. In future articles we will show you what an optimal technology environment for payment integrity and cost containment looks like. 

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