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Optimizing your payment integrity program

How much is your payment integrity plan really costing your business?

Did you know that 7-10% of all medical claims are paid incorrectly? That translates into millions of healthcare dollars lost to billing errors, abuse, and waste. The American Medical Association previously estimated that eliminating health claim payment errors would save $17 billion.1 Yet, payment integrity is often regarded as a back-office operation that is secondary to more strategic, reform-driven initiatives.  However, some key tenets of healthcare reform mandate that healthcare executives pay closer attention to payment integrity performance and develop strategies to strengthen it.

With the changes in healthcare reform capping premiums at their current rates, plans must emphasize profitability, which means reducing medical claims expenses to remain viable in the marketplace. The first step in doing so is to identify the challenges that may be affecting your plan’s payment integrity capabilities and understand how these challenges are impacting your business.

Challenge #1: Dispersed data and tools

Data needs to be stored in a consistent format, with universal access to those who need it.

Payment integrity usually happens in multiple claims areas within a typical health plan with several points of contact. Additionally, IT issues surrounding the storage of information and data—whether it’s in an Excel spreadsheet or an Access database—cause a further splintering of information across the organization. With multiple versions of stored data being housed in different departments and in different formats, there isn’t a single data access point where caseworkers and managers can find the same version of the truth. The result is a lack of integration that could result in important, updated information not getting transmitted to the right department at the right time.

Challenge #2: Reporting is often manual and inconsistent

Reporting needs to be timely, automated, and consistent.

Many healthcare plans lack a current and accurate picture of their payment integrity cases and recoveries. Because data is created and housed across various departments and vendors, most reporting tends to require time-consuming, manual integration of this data. This results in infrequent and inconsistent information. Without access to the right information at the right time, management can’t identify the indicators that are contributing to a plan’s performance; nor can they track which cases have the highest recovery rate or cost avoidance opportunity. Reporting should be done by vendor, by recovery area, and by cost avoidance instances to allow full visibility into your recoveries. Implementing automated case management and reporting systems also contributes to the overall efficiency of the organization, producing timely reports with the most current information.

Challenge #3: Lack of transparency leads to inability to forecast

Dashboard access to real-time information results in better visibility and compliance.

Transparency is critical for measurement. Quite simply, you can’t improve what you can’t measure. A lack of transparency in your data results in a lack of trust in the process, in the data itself, and in the results. For managers to accurately forecast, they need full access to trusted data to identify trends and recognize indicators of success. Your in-house team isn’t alone in requiring transparency. Without transparency, it’s difficult to fully meet compliance requirements that could call for an audit trail of your data. Dashboard analytics meet these standards by providing a real-time status of your recovery inventory, with detailed reporting of backlog, case type, and recovery status.

Reducing medical claims expenses and maximizing payment recoveries

Faced with all of these challenges as well as the demands of new healthcare legislation, it is now imperative for health plans to improve their bottom line. Reducing medical claims expenses—which account for 75% of every dollar—is crucial to a health plan’s survival in this market. If plans can improve and optimize payment recoveries by even two percentage points, that translates into tens of millions of dollars, ultimately allowing the plan to thrive, not just survive.

Solution: Ajilitee’s solution improves and optimizes payment recoveries

Ajilitee is a full-service healthcare information management, analytics and business intelligence consulting firm with deep experience in the payment integrity space. We offer a solution to improve and optimize claims recoveries and cost avoidance for your organization. Our award-winning information experts analyze your recovery operations to determine what works well and where improvement or change is needed. Our team develops a results-based analysis and delivers a solution plan for improved performance. Ajilitee’s team has the business acumen, industry expertise, technical proficiency, and consulting excellence to optimize your payment integrity challenges and begin improving cost avoidance capabilities.
1 Healtcare IT News, June 20, 2011