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The Agile Incubator Blog

Expected outcomes with a successful payment integrity program

A holistic review of payment integrity and cost avoidance can reveal millions of dollars in savings

How do you know if your current payment integrity plan is working?

If you are executing with the right approach, positive outcomes should be easy to see. At Ajilitee, we’ve developed an approach we call the Cost Containment Checkup, which includes a deep dive analysis of a health plan’s payment integrity landscape across multiple areas – from subrogation and coordination of benefits to claims review, audits, and more. By looking at your plan’s payment integrity from this enterprise perspective, you can find opportunities to save and recover more money by investing in common technology, capturing and sharing data more effectively, and simplifying processes.

Using this approach, our clients have seen dramatic results, including the findings that a plan in the Northeast could save $40 million over a year and a half by improving their recovery and cost avoidance from 1.4% of overall paid medical claims to 2%. This goal is achievable with a payment integrity program that combines comprehensive metrics, reporting and analytics, and improved technologies. Most importantly, that .6% translates into $40 million in opportunities to increase this plan’s bottom line—and that’s not small at all.

Your health plan can experience the same boost to its bottom line with an effective payment integrity program. Ajilitee’s approach is market-tested with proven results and aims to solve payment integrity issues at their root. Ajilitee starts with a comprehensive unbiased analysis of your payment integrity program that looks across all the areas of cost containment and presents a roadmap toward achieving your goals. The rising cost of healthcare is a burden to everyone in the industry and optimizing payment integrity is a powerful tool to harness it.

Optimized resources and recovery teams

Health plans typically use a variety of vendors, both internal and external to manage their payment integrity program. These recovery teams should be delivering a maximum and measurable return on investment. Your analysis of these teams should deliver a breakdown of performance by recovery area, outlining which resources and vendors are the most productive and the best value for the outcomes. Often, internal teams can perform better at a lower cost. In this case, you may decide to go in-house rather than outsourcing certain tasks. As an example, one health plan enlisted eight vendors to assist with recovery efforts in a variety of areas. A closer analysis by Ajilitee’s consultants revealed that three of those vendors were delivering 75% of the recoveries, highlighting an opportunity to realign resources for maximum results.

It is also important to streamline all of these resource touch points into one database. This allows you to automatically send extracts out to the vendors as well as intake vendor files. Ajilitee deploys a case manager tool in its cost containment efforts that automatically identifies a case and assigns the appropriate vendor. This results in a more seamless process for maintaining resource and data files and makes future reporting much more efficient.

Optimized process and technology

Technology is critical to optimizing your payment integrity process in many areas of recovery: subrogation, COB, mass tort, etc. Data mining, data matching, and predictive analytics can quickly identify more cases for recovery or cost avoidance and can do so with a high degree of accuracy. With automated workflow technology, there are fewer manual hand-offs of your data, which results in fewer errors, better prioritization, and better case management.

Dashboard analytics capture critical data that can be used to track efforts across all of your payment integrity areas and can be shared quickly with management. With data accessible at-a-glance in real time, you can drive better decision making in a timely manner. Executing decisions in these moments that matter, rather than looking at the data in hindsight, results in better outcomes and more cost savings. With this data in hand, you can see what work is in process, what the value of that work is, where you’re performing well and where you need help. This also ensures that plans are prepared for compliance requests, with a reliable data trail and the appropriate documentation.

Maximized outcomes

Once you have the right resources in place, your data is flowing well, and your tracking and reporting is optimized, then your plan should begin to see maximized outcomes across your payment integrity caseload. Determining which cases are the most recoverable, whether it’s subrogation or COB, is key to achieving the maximum return on investment in your payment integrity program. Previous work with clients has helped Ajilitee identify particular areas, including DRG, COB, and subrogation, where plans could find the biggest ROI related to the recovery improvement suggestions we made. With expanded work in these targeted areas, cost avoidance capabilities can see measurable improvements over time.

As plans start to realize success in payment recoveries, attention can be turned to paying claims right the first time. Inaccurately paid claims often stem from inaccurate eligibility information. Maintaining an up-to-date and consolidated eligibility hub that looks across all areas of eligibility will help maximize outcomes and ultimately solve payment integrity issues at their root.

Ajilitee is the right solution

Ajilitee has many years of experience in the payment integrity space and we have proven results to demonstrate our success in this arena. Our expert, unbiased, and comprehensive approach is executed by our team of consultants who understand your business, know the current healthcare landscape, and can deploy the right technology to improve your cost containment capabilities. Ajilitee’s proprietary database of benchmarks will help you understand your plan’s strengths and weaknesses. Using our benefits calculator, we will give you a dollar figure on how many millions—or tens of millions—could be recovered by your health plan through an optimized payment recovery process. Partnering with Ajilitee will give you a road map to an improved bottom line and a sustainable path toward future success.