Navigating a complex landscape: How payers can simplify payment accuracy and drive better results

Determine payer responsibility and maximize recoveries

 

The healthcare system continues to become more complex and costly. With U.S. healthcare spending growing at a faster rate than Gross Domestic Product , according to the Centers for Medicare & Medicaid Services (CMS), there is a laser focus on ways to contain costs without sacrificing care.

Healthcare insurance plans, or payers, play a central role in this healthcare system landscape when it comes to costs. One way they can effectively control costs is by fully leveraging payment integrity programs to find overpayments they have inadvertently made to providers during the claims payment process.

The U.S. Census Bureau reports approximately 43 million Americans have more than one type of health insurance coverage . Accurately paying medical claims is very challenging because claims must be for the right amount, to the right provider, for services that were appropriate — and they must be submitted in very exacting ways. In addition, there are tight time constraints.

Any mistake in coding accuracy, payment responsibility, contract compliance, clinical appropriateness, or other areas can result in rejected claims which must then be reworked. Rework is a major source of cost and abrasion for providers and members. Added to those complications are industry payment guidelines and regulatory requirements which must be followed and continuously change — usually without notice. Some plans hire vendors to address their payment integrity needs, while others bring payment integrity in house.

 

Effective Other Party Liability Solutions cut through the confusion and find answers

 

One of the most valuable ways payers can contribute to their cost containment efforts is by ensuring they are paying only the claims for which they are responsible. Typically, this is achieved through coordination of benefits (COB) programs which determine the payer order in a set of circumstances. However, in some cases, such as car accidents and class action lawsuits, payer responsibility shifts from COB to subrogation. Carelon Payment Integrity has bundled two of its most advanced solutions — Full-Service Subrogation Solution and Coordination of Benefits Solution — on a single platform to create Other Party Liability (OPL) Solutions, a comprehensive approach to determining payer liability when multiple insurers are involved.

Leveraging OPL, plans can consolidate and simplify their payer responsibility programs and derive more value using a single vendor. When you partner with Carelon for OPL, you benefit from the right technology, analytics, and expertise to find accurate answers. Automation creates efficiencies while insights drive even more valuable results.

Claims too complex for automation are reviewed manually by subject matter experts. An online workflow tool facilitates communication and validation with clients. “The solution accomplishes in one eight-hour day what would take 12 full-time employees a month to process manually and with fewer mistakes,” Richardson says.

Subrogation also benefits from automation and a proprietary workflow tool.

The technology supports the highly trained investigators, specialized analysts, and negotiators as they perform their critical tasks.

Carelon's single platform for OPL Solutions streamlines and empowers

 

Carelon’s single platform for OPL Solutions works seamlessly and transparently, improving administrative efficiencies, driving higher yields, and promoting greater trust between stakeholders. The result of decades of learnings, Carelon partners with plans collaboratively, providing solutions that put them back in control.  

“Subrogation and COB are two sides of the same coin,” Browder says. “The goal is to manage claims payments effectively and fairly. With a single vendor, payers find that processes are streamlined, and issue resolution is simplified. There is consistency and reduced complexity.”

 

 

A proactive approach ensures better results

 

Richardson and Browder both emphasize how important it is to act preemptively. “Our Full-Service Subrogation Solution embraces a proactive, data-driven approach, using sophisticated data matching techniques throughout — from identification to post-recovery. We want to find opportunities early so we can assess and prioritize those opportunities and get the best outcomes for our clients,” says Browder.

For COB, understanding medical markers and anticipating how life event changes can impact coverage are imperative. “Knowing that certain medical events are often linked and watching for possible coverage changes as a result of it — a sudden disability, for example, or knowing a baby is on the way and anticipating it so it can be reflected in a plan’s membership files is key,” Richardson said.  

 

Customization puts the client first

 

“Health plans work with numerous entities including providers, members and customers, employer groups, CMS, and state agencies, all of whom have different needs,” says Browder. “We are born out of a health plan, so we have unique perspective that traditional vendors just don’t have and can anticipate and meet those needs.” 

“We work with our clients to help them achieve their goals, offering customized reporting, special rules configuration, and communications approaches that work for them,” Richardson says.  

 

Focusing on the future

 

Clients want to maximize recoveries, accelerate resolution, contain costs, and attain the best customer satisfaction possible. A strong OPL program such as the one Carelon Payment Integrity offers delivers on all those objectives. An end-to-end approach with a single vendor makes it even better. “Plans are looking for less complexity and burden when it comes to payment integrity,” Browder says. “They want to know they can turn it over to the experts and it will get done the right way. That’s where we come in.”   

Carelon Insights is making payment integrity more efficient and proactive than ever before. Contact us to learn more about the possibilities and positive impact of our Other Party Liability Solutions.