How payment integrity is evolving: Five questions with Carelon Payment Integrity leaders

If there’s one thing that the Carelon PI leaders have learned over the course of several decades of being immersed in the payment integrity space, it’s that the industry is constantly evolving and improving. Here, they discuss the evolution of payment integrity and how the focus today is not only on correcting payment integrity problems but also on preventing them in the first place.

Finding the best ROI

You have all been involved with payment integrity for quite some time. How have you seen it evolve over the past 15 years?

James Brady, Vice President, Carelon Payment Integrity Commercialization – Payment integrity first existed as a clean-up function to help when there were claim processing errors. It has evolved into a much broader capability which can address a wide range of medical claim payment errors such as inaccurate coding, duplicate payments, and contractual mistakes. Health plans took the opportunity to build out internal solutions and engaged vendors to create greater value. This is where the payment integrity world exploded. Over the years the vendor market has changed; today, while there are many small point solutions there has been a great deal of consolidation. When COVID-19 hit, the world started to shift because of cost pressures and concerns of a recession.

Of course, payment integrity programs have always been under pressure to lower costs and increase ROI, but in the past few years, those priorities have become even more important. Payment integrity leaders still need to fight fraud, waste, and abuse, but they have to do so even more cost-effectively — while preserving valuable provider and member relationships and creating better accuracy and efficiency.

From reactive “point” solutions to end-to-end solutions

How is Carelon leading payment integrity innovation?

Emily Pera, Vice President, Carelon Payment Integrity Strategy – We’re breaking down the silos. Payment integrity has historically been focused on solving each problem individually with vended solutions, but the more optimal way for the ecosystem to work is as an integrated set of end-to-end solutions. At Carelon, we’ve been solving problems for health plans for many years. Our solutions aren’t point solutions, they’re end-to-end solutions, and that’s one of the reasons why we’re able to get such good results. We use analytics to find overpayments and then resolve them with automated operational workflows. We also create insights to identify the root causes of errors and partner with providers to prevent those errors in future claims.

We’re fortunate because we have such a large client base — serving over 40 health plans with more than 43 million members — that we get to solve the kind of problems that occur holistically across an entire ecosystem. Our integrated solutions allow us to mobilize the most effective solution for any given error.

Applying the right technology toward the right solutions

How does technology play into those capabilities and enhance them going forward?

Cory Deagle, Vice President, Carelon Payment Integrity Product Management – Technology is the foundation of everything we do. It allows us to discover new types of errors that can’t be identified by even the smartest human beings. It allows the sum of the parts to equal an exponential value beyond what we ever thought possible. Our technologies make it possible to solve problems that weren’t solvable five years ago. When we combine that tech with our team of the most highly experienced healthcare reimbursement professionals around, it adds up to our incomparable secret sauce.

There are a lot of buzzwords out there: we talk about AI and machine learning. All these parts and pieces are fun to talk about, but the reality is they’re only good if you can apply them in usable solutions. That’s the real value of what Carelon delivers — the integration of technical capabilities into real solutions.

Identifying and solving “hidden” problems

Do you have an example of a solution or product that embodies this approach?

Emily Pera – Absolutely! Our Coordination of Benefits (COB) Consensus solution has helped us save billions of dollars for our clients. Every health plan does coordination of benefits, but it’s an area that can usually be improved. For most plans, it is a highly manual, expensive, and complicated process. Payers find it difficult to effectively work “other health insurance” leads because they lack the necessary information, expertise, and technology.

Cory Deagle – Our approach is to get the eligibility correct as early in the member journey as possible and create a frictionless experience for our members, providers, and customers. We accelerate the identification of other health insurance coverage that members might have, and streamline the process of determining the responsible primary payer. As a result, leads can be processed faster, more accurately, and more efficiently. That means we can process an increased volume of leads and increase our clients’ return on investment. Then, our workflow tool prioritizes leads and escalates complex ones, separating cases that must be reviewed manually ensuring resources are effectively utilized.

Getting it right the first time

Where is payment integrity headed?

James Brady – Payment integrity is headed toward more integrated and transparent solutions that help the provider and the payer promote payment accuracy before a claim is submitted. A lot of errors happen because of the complexity of billing and coding rules - it's not intentional. When we create better transparency, we can break that cycle of claims being rejected or denied and reduce the stress on a plan’s relationship with providers.

With today's technology, we can solve problems so providers can bill more accurately, and payers can allow those claims to be paid accurately the first time. That makes for a better provider experience. Payment integrity can reduce rework, improve payer/provider relationships, and lower the overall cost of healthcare — and those savings can be passed to our members. That is a big part of payment integrity’s future.


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