The United States spends more on healthcare than any other country. And that’s not going away. The U.S. Centers for Medicare and Medicaid Services project spending to increase about 5.4% each year, reaching $6.2T by 2028.

Studies published in the Journal of the American Medical Association found that approximately 30% of healthcare spending (aka somewhere between $760B and $935B) is considered to be waste, further underlining the need to reduce overtreatment, improve care, and address overpayment.

Moreover, in 2020, health insurance companies were averaging a 6.27% error rate. High-cost claims (defined as at least $35K) are a critical focus area for health plans seeking to address waste, reduce provider abrasion and improve savings.

The Challenges

Health plans face myriad challenges related to the capture, management and collection

of revenue from patient services. And over time, the administrative and clinical claims process has only become more complicated, nuanced, and costly to navigate, jeopardizing optimal reimbursement and financial return.

Payment integrity issues can be difficult to rapidly isolate and correct, yet timely identification is crucial. Typical pain points include:

1. Profit optimization

A health plan may not achieve desired cost savings with current approaches. For example, post-encounter recovery can take a long time, and in many cases, the payer may not be able to secure full or even partial payment.

2. Provider abrasion

It is important to maintain a balance between optimizing savings and preserving payer-provider relationships, a common source of friction in the claims process. The goal? Prevent balance billing.

3. Processes

Inefficiencies, changes, new implementations, provider appeals, sensitivity to provider impact and the administrative burden of records retrieval are common process-related problems.

4. Cost of payment corrections

Overpayment, chasing unrecovered payments and post-payment reviews all contribute to health plan costs.

5. Expertise and staffing

Health plans are realizing the costs associated with the right internal expertise and volume of FTEs to effectively deal with complex or specialized claims, ensure coding accuracy, and allow for scalability.

6. Complex ecosystems

Navigating the maze of healthcare systems and third-party billing partners can be difficult in a disconnected and ever-changing environment of regulations, contracts, technologies, and coordination steps. The costs and time required to get a comprehensive patient record for a medical review of adjudicated claims can make paying a claim in a set amount of time even more difficult.

7. Turnaround time

For high-cost claims, health plans are looking for ways to increase efficiency and speed, given the levels of both payment and risk.

Expanding Financial Capture to Address Complex Claims

Payment integrity solutions continue to evolve in terms of technology, strategy, and services

to address health plans’ unmet needs for higher claim accuracy and the reduction of improper payments in high-cost inpatient and outpatient facility claims.

Thirty-three percent of current healthcare expenditures lie within the hospital setting. And around 70% of provider-submitted claims have incomplete or incorrect data. As such, with the right strategy, there is a large opportunity for financial savings.

That strategy? Address errors prior to payment, rather than via traditional “pay-and-chase” approaches, in which claims are reviewed post-payment.

Assessing claims post-adjudication and prepayment eliminates the costly pursuit of refunds of overpaid monies, additional case reviews between the health plan and provider, and the potential for provider abrasion.

While many health plans are actively searching for third-party technologies, expertise to support timely payment (in less than 30 days), and records retrieval, the right combination of analytics, process improvement strategies, subject matter expertise, and effective and responsive client support services will enable health plans to achieve optimal results from payment integrity programs.

In Conclusion

Better adjudication of complex, high-cost inpatient and outpatient claims prior to payment is the only way forward.

While getting started might seem difficult, finding success is attainable (and relatively simple). Through a combination of utilizing your best human capital assets, third-party partners, and technology, you can ensure you optimize processes, minimize turnaround times, and reduce the number of appeals, while still maximizing returns.

For access to additional information, visit Zelis’ No Surprises Act Information Hub.