Prior to the pandemic, claims fraud, waste and abuse (FWA) was a priority issue for health plans aiming to improve both care quality and the member experience. But, accelerated by the pandemic, health plans are now grappling with compounding operational challenges — from aberrant services related to COVID-19 diagnoses, to service shifts, to uncontrolled telehealth expansion and, of course, labor shortages. These converging challenges has brought a sense of urgency to the need for a new payment integrity (PI) architecture, including complete process re-engineering and AI, automation and analytics enablement.

How can payers address these now-pressing PI needs while also planning for future financial prosperity to come? Here are three outcomes of the heightened PI pressures, along with guidance on how to solve for these challenges.

1. Pandemic-driven volume and resource fluctuations

On top of legacy waste and abuse issues affecting claims processes, the COVID-19 pandemic adds news challenges in excessive COVID-19 diagnosis, extended visit durations and increased visits for therapies and early refills and disbursement of excess prescribed quantities for pharmacy and durable medical equipment (DME). These added complications impact forecasting of utilization and payments accuracy.

Projected return-to-normal volumes have been met with varying results across payers. Some payers have seen an increase in deferred care but often not at the anticipated levels, while other payers had higher than expected deferred care. Other plans are seeing continued declines in enrollment.

The operational challenges associated with unpredictability of payments and bills have only been exacerbated by the labor shortage. On top of enrollment declines, many health plans struggle with remote work, resource reallocation to support critical COVID-19 initiatives and the resulting recruitment and retention of billing staff.

All of these operational challenges often lead to increased billing inaccuracies and payment errors. In addition to agility and flexing to meet seasonal shifts, another challenge lies in leveraging data to identify the aberrant providers, erroneous claims and incorrect payments.

Designing a program to accommodate these fluctuations and resource challenges requires an elevated people, process and technology approach. With the right payment integrity expertise, organizations can step up audit accuracy — with rules and query writing for a prepay focus.

A proactive and preventative pre- to post-pay approach may exponentially drive down inaccuracies and overpayments for improved recoup for payers over time. Experts can provide top-notch analytics tools and techniques that are combined with automation, machine learning, custom configuration and manual review and intervention to analyze the claims data. The right experts deliver a brain-bot combination, bringing the human ingenuity via skilled, experienced payment integrity specialists. Finally, the right payment integrity expertise requires robust internal business analytics solutions that depend on knowledgeable resources across IT, PI and the SIU to maximize actionable findings.

2. Evolving regulatory landscape

The pandemic has brought swift changes in regulations and policies to ensure access to patient care. Health plans have been burdened with more and more administrative lift as well as increased regulations focused on greater transparency in billing processes — beyond the already tall order for modern-day member care and experience. Now these plans must keep in-step with federal government regulations while also enforcing individual state mandates regarding “non-essential” claims processes and review of COVID-19 related claims.

Among the many pandemic payment fallouts, this scenario is played out daily: a patient with coronavirus symptoms undergoes not just the COVID-19 test but possibly other tests to rule out respiratory problems. Confusion around payment, services and improper coding are just a few of the factors that can then result in a surprise bill. This bill starts a long and expensive journey to correct coding and payment — at a significant loss to all parties: patient, provider and payer. This surprise bill is today a key focus of the No Surprises Act relating to how providers and payers will communicate with individuals on hospital billing of payers and will also make the reconciliation process more complicated.

Ultimately, new government regulation, COVID-19 requirements, exceptions and payment-related complexities have only intensified payment integrity challenges.

PI experts can provide the deep domain expertise and understanding of quickly-evolving rules and regulations, augmented by the requisite highly-trained claims and coding expertise. Payment integrity solution providers also have the stringent attention required to improve accuracy of information between provider and payer. This helps to ensure that there isn’t a post-pay audit issue associated with the par/nonpar provider in relation to new regulations around billing processes.

3. Rapid increase in telehealth services

Early in the pandemic, telehealth utilization surged as consumers and providers sought ways to safely access and deliver healthcare. At the core of COVID-19 disruption are emerging services and new medical coding and billing procedures — with telehealth at the top of the list. A significant number of health plans expanded coverage for telemedicine and telehealth services related to behavioral health, specialist visits and primary care, to allow people to receive care while remaining safe at home.

Research showed that overall telehealth utilization for office visits and outpatient care was 78 times higher in April 2020 than just two months earlier, in February 2020.

In addition to the patient/member-centric benefits of easier access to providers, telehealth also brings potential coding and payment aberrations. For example, the risk of coding e-visit or virtual check-in claims to higher-level telehealth visits, as well as up-coding of evaluation and management (E&M) services to a higher level of service than actually rendered. Research from Medical Billing Advocates of America found medical bills with errors are up 80% and we’re likely to see more of these grim statistics.

Health plans are experiencing a clear need for highly trained coding resources that can meet CMS timelines and unforeseen resource demand. The right PI experts will bring right-shoring of cost-effective resources that are highly trained AHIMAs or AAPC-certified coders. These types of professionals can further scale and complete projects of varying sizes with the maximum level of accuracy following a proven quality assurance process.

As expert problem solvers, payment integrity solution providers bring a strong grasp of the nuances of the COVID-19 impact, including the regulations and how they can affect business operations holistically.

The global reach of some of these service providers allows for right-shoring models that ensure compliance standards are met while still providing cost and operational optimization, with the implementation of new tools, such as analytics, AI and automation.

The healthcare industry presents a complex lifecycle of stakeholders with financial impacts and experience expectations — and payers must answer to all of them. With the right payment integrity approach and finely tuned focus, payers will find the exceptional service execution required to thrive in today’s environment.


This content, Addressing 3 Pandemic-Induced Integrity Challenges, was originally shared by Healthcare Dive on January 30, 2023.

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