How Plans Simplify Payment Integrity by Choosing the Right Partner

Effective payment integrity ensures that provider claims are processed efficiently and paid accurately. What’s more, a streamlined payment process reduces friction between payers and providers, saving time and energy as well as bringing stability and predictability to reimbursement.

To facilitate greater efficiency in their payment integrity efforts, healthcare payers have many options, including utilizing multiple vendor partners or streamlining to one comprehensive partner.

A best-of-breed approach looks to adopt a solution from the industry leader for each part of the healthcare claims review and payment process. On the surface, this procurement strategy prioritizes the value of given technology to help a payer improve one or more aspects of claim management and reimbursement. But the approach also introduces unintended consequences.

“A best-of-breed approach seems like a viable and very attractive way to go,” says Zelis Chief Medical Officer Timothy Garrett, MD. “You’re not tying yourself to one vendor. You’re actually taking the best of all worlds. However, what doesn’t get considered in those decisions is the cost — yes, the financial cost but also the cost in terms of effectiveness. It’s the cost in the number of hours a payer’s staff will need to manage multiple non-integrated systems. It’s the cost in relationships with your providers.”

More solutions mean more relationships and technologies to manage and the potential for many breakdowns along the way.

Alternatively, choosing a single payment integrity vendor enables a one-stop shop with a slew of additional benefits. This approach is becoming an attractive solution to payers increasingly more interested in benefits design and care management than adjudicating claims and making claims payments.

“A one-vendor payment integrity solution is often the best choice because it allows a payer’s internal teams to direct their focus to strategic areas,” Garrett maintains. “Of course, some payers, especially large organizations, may have more needs than a single vendor can supply. Even still, minimizing the number of vendors is of tremendous value in streamlining operations.”

Data represents a significant benefit. A multitude of technologies creates a commensurate amount of information that must then be brought together to achieve visibility across the various parts of the claims review and payments processes.

“A single vendor can make use of a single data source that can be used for several purposes. For example, that one feed can support both editing functions and clinical reviews. And then having a single, go-to person within a single vendor who can help simplify troubleshooting when something seems to not be going right is a big advantage,” adds Garrett.

Another benefit comes in the form of a more streamlined implementation.

“Supporting the implementation of multiple different payment integrity vendors can be a heavy lift for payers, and that’s because vendors have differing abilities to integrate their IT systems with payers,” Garrett explains. “And of course, payers also have their own number of IT platforms. So having to support the implementation of all those numerous interfaces and processes as well as interacting with a host of different people across vendors can stretch a payer staff thin.”

Making the right choice

Choosing the right vendor comes down to asking the right questions about people, process, and technology.

According to Garrett, payers must first and foremost evaluate vendors based on the ability of the latter to serve as a true partner.

“Ensuring that a payment integrity vendor is truly acting as a partner is the most important aspect of choosing a vendor. Payers should ensure that the vendor is updating their content regularly and remaining in tune with the payer’s needs. All of that is based on open, honest, and transparent communication between the two,” Garrett emphasizes.

Another key question focuses on the breadth and depth of a vendor’s operations.

Those with a nationwide reach “have the ability to identify solutions that can be helpful not only for a specific payer but also for a wide range of payers,” says Garrett. “In other words, a solution that proves effective for a specific payer can then be deployed to others. That’s the network effect.”

The notion of partnership should also extend to balancing how internal and external resources are best utilized.

“Some payers outsource a great deal of their payment integrity work, and some keep most of it internal. So, it very much depends on the makeup of a payer’s own staff and areas of expertise,” Garrett observes.

“A good vendor can help a payer identify areas of strength,” he continues. “The vendor can talk with and help the payer identify what things to keep in-house and those to be outsourced. Sometimes it is more cost-effective to keep things internal. Other times, payers are not getting the results they want. A true partnership helps close those gaps.”

For payers to improve and scale their operations, they must look inward at their capabilities and outward for solutions that address their weaknesses. Given the growing complexity of healthcare payments, partnering with a payment integrity vendor with a comprehensive lens through which it can bring certainty to claims, reimbursement, and provider relations is simply common sense.

__________________________

Zelis harnesses data-driven insights and human expertise as scale to optimize every step of the healthcare payment cycle. We partner with more than 700 payers, including the top-5 national health plans, Blues plans, regional health plans, TPAs and self-insured employers, 1.5 million providers and millions of members, enabling the healthcare industry to pay for care, with care.