How payment integrity is evolving

Finding the best return on investment

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: 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: We’re breaking down the silos. Payment integrity historically focused on solving each problem individually with vended solutions. This isn’t the most optimal way for the ecosystem to work.

At Carelon, we’ve solved problems for health plans for many years. Our solutions aren’t point solutions, they’re comprehensive 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: 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 to 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 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, reducing the stress on a plan’s relationship with providers.

With today's technology, we can help providers bill more accurately, which allows claims to be paid accurately the first time. That makes for a better provider experience. Payment integrity can reduce rework, improve payer and 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.