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The Agile Incubator Blog

Lack of information transparency and benchmarks hampers the payment integrity organization

 

In my last blog post,  I discussed some of the challenges healthcare payers face related to their lack of transparency into recovery performance results at a program level. In this post, I’d like to dive deeper into the problems caused by lack of transparency into payment integrity performance and how we have seen organizations successfully deal with these challenges. If your payment integrity organization is plagued by manual reporting processes, multiple versions of the truth, and analysts spending the majority of their time gathering data versus performing value added analysis, then this post is for you.

Insufficient transparency and recovery performance reporting

Transparency is rapidly emerging as a key issue for healthcare payers. Internal payment integrity stakeholders require transparency related to payment integrity recovery performance results in order to be successful.

Healthcare payers frequently rely on manual reporting to manage payment integrity, using tools like Excel and Access, which don’t provide automated reports or interactive dashboards that allow them to see recovery performance by recovery area and vendor on a timely basis. This situation often leads to issues including multiple versions of the truth, difficulty in forecasting future recoveries accurately, and decisions based on intuition versus facts. In addition, there are no widely accepted industry benchmarks available by recovery area, which makes it difficult for payers to know how they are performing related to their peers.

As part of payment integrity performance reporting, comparisons of actual to target recovery performance by recovery area is needed (e.g. COB, subrogation, provider audit, Medicare Secondary Payer, etc.). Target recoveries by area should be based on well-established industry benchmarks that consider the line of business along with state and federal laws. Industry benchmarks should provide recovery targets as a percentage of the total medical claims expense along with year-over-year trends over a minimum period of several years.

Payment integrity reporting should include additional reporting transparency in the following key areas:

  • Cost avoidance that includes tracking specific cost avoidance recoveries that includes COB, contractuals,  benefits, etc.
  • Work inventories by recovery area including current status, recovery value estimates, and prioritization
  • Revenue performance including expected versus received revenue
  • Internal staff and vendor performance tracking
  • Productivity reporting including updates, time in process, time to outcome, aging, and backlogs
  • Vendor performance including goals, cost, and service level agreement tracking

A comprehensive payment integrity dashboard will show the recovery results along with their respective targets with visual indicators to see how each measure is performing against their targets at-a-glance. There are filtering capabilities by line of business (e.g., Medicare Advantage, Commercial, Medicaid, etc.). The payment integrity dashboard should be designed to be used by the general workforce as effective dashboards should be easy to understand and use. The displayed data should be automatically updated without any assistance from the business user. The frequency of the update will vary by organization and by purpose, but operational payment integrity dashboards should have data updated on at least a daily basis.

Conclusion

The payment integrity organization frequently has many challenges related to the need for increased transparency. Transparency is required to understand the overall program level performance needed to make improved, fact-based decisions and to take the necessary actions needed to improve performance. To meet the reporting challenges, a self-service, interactive dashboard reporting environment should be created that will allow the payment integrity business users the ability to see how they are performing against industry benchmarks at-a-glance.