Improving Payment Integrity with a Building Blocks Methodology

Healthcare costs are increasing, and health insurers can expect — by some estimates — to spend 7 percent more in 2024. In this environment, payment integrity teams have a strategic imperative to optimize.

But that same economic dynamic demands smart investments. To get buy-in on progressive strategies, payment integrity leaders must determine the right time to invest in programs with a keen eye to value.

Tareyn Gillilan, currently VP of Business Operations with WellSense Health Plan, has developed a scalable and understandable framework for investing in payment integrity. Over her last ten years leading payment integrity strategy at different health plans, this methodology has proven successful in creating value for programs at various stages of maturity.

“To engage at the highest levels of organizational strategy, payment integrity organizations need to be able to handle change and create financial value,” says Gillilan. “That’s true whether the directive is accelerating growth, building from scratch, or somewhere in between.”

5-STEP BUILDING BLOCKS FRAMEWORK

The framework Gillilan has found success working from can elevate a payment integrity program or team working from any level of maturity.

“I rate payment integrity program maturity across five basic dimensions: emerging, limited, developing, centralized, and optimized,” Gillilan maintains. “In just the past five years, I’ve seen payment integrity organizations mature to where a much greater percentage see their programs on the developing or centralized side of the continuum.”

With that rate of progress in the industry, a predictable, logical approach to taking the program to the next level can prove invaluable. The five steps in this building blocks framework are simple and repeatable, so it can grow with an organization as it further matures.

1. Assess the program’s people, process, and technology

The first step of the methodology is getting a full accounting of the current state. That can begin with a straightforward listing of the programs, teams, and/or support operations involved in the strategy, ordered by their relative financial impact. This list can include payment integrity verticals as well as supplier management, data and analytics, group management, provider scorecarding, and more.

Then, each can be evaluated on its three primary building blocks: people, process, and technology.

“I like to use a red-yellow-green color code because it’s intuitive and easy to assess at a glance,” notes Gillilan. “Broadly speaking, those indicators tell me if my people, process, and technology blocks are not available, need work, or are fully operational.”

Gillilan often completes this assessment in a group whiteboard session. What emerges is a fuller picture of where the program stands — as well as where it can go.

“When you push yourself to assess where you stand, you also start figuring out that vision of the future, which gives you a great platform to get needed buy-in,” Gillilan explains. “Executive leaders will be very interested in what potential results you foresee.”

2. Identify the specific constraints

Once the initial assessment of the programs and support operations is complete, the next step is to identify what — specifically — has held back progress on key initiatives.

Payment integrity leaders routinely cite staffing and budget challenges as their top barriers to innovation. But those are not the only constraints and may prove too big or vague to be actionable. Depending on the payer’s unique situation, challenges may include:

• Savings targets with annual increases
• Manual processes and/or outdated technology
• Long corporate planning timelines
• Organizational complexity and/or misalignment
• Change management

As payment integrity organizations move along the maturity continuum, these constraints increase in complexity.

“It is much easier to move the business in the early stages of maturity with simple changes like spreadsheets or a single hire,” says Gillilan. “But further developing programs into centralized or fully optimized operations requires much more energy to create incremental change.”

3. Identify the building blocks needed to grow and mature

Based on the assessments completed and the constraints identified, the next step is to lay out the initiatives needed to grow and mature the building blocks of the programs. Brainstorming with the team, independent research, and experiences from past roles and the broader payment integrity community are all great sources of ideas at this stage.

In the earlier stages of program development, small changes can create big impact. But for many insurers, updating legacy technology systems to take advantage of automation and other advanced capabilities is driving many of these initiatives.

“I cannot move from a centralized to an optimized maturity model without enterprise technology,” Gillilan stresses. “And that investment is often accompanied by huge amounts of training as well as organizational restructuring of associated teams.”

4. Prioritize investments based on quickest path to ROI

There are two primary considerations when evaluating initiatives based on projected return on investment. The first is looking at programs or teams with the greatest financial impact. But this framework highlights another high-potential consideration: areas where the building blocks are out of balance.  

“If I put all my money into great technology but don’t staff or maintain it, I’m never driving that value. And the reverse is true, too. I can hire the best people in the world, but without process or technology, they can’t perform their best,” warns Gillilan. “Closing those gaps where you’re out of balance is a sweet spot to drive immediate and incremental value.”

5. Reassess regularly to identify additional opportunities

Once the new investments begin to show their ROI, this framework can be referred to and built upon time and again.

“Payment integrity is not a one-time project,” says Gillilan. “But when you put the time and energy into these assessments, they hold. I use this framework to show our progress every time I go to a quarterly executive readout or during annual budgeting, making minor adjustments as needed.”

LESSONS LEARNED FROM OPERATIONALIZING THE FRAMEWORK

Pursuing this framework reinforces that big changes can happen in small steps, which can reduce the perceived risk associated with innovation.

“Incremental improvements can drive significant ROI,” asserts Gillilan. “Demonstrating progress against a goal to ensure buy-in for the next step creates a stronger foundation and alignment across the business.”

In the end, it’s about an industry-wide goal of what can happen when every payment integrity program is focused on full optimization.

“What would it look like if our teams were fully data centralized? What if our providers had instantaneous access to information about edits that will be applied? What if we had AI-driven adjudication?” Gillilan poses. “There’s so much potential for innovation in payment integrity. And with a methodical approach, it’s fully achievable.”

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More than 20 health plans representing over 70M members use ClarisHealth’s Pareo® technology platform as their industry-standard operating system powering enterprise payment integrity. They are reducing manual work, gaining insights into operational performance across lines of business, and accelerating their strategy to overpayment prevention – at a significantly reduced cost.