Five Essentials for Healthcare Payment Accuracy in 2020 and Beyond

January 9, 2020 HMS

It’s 2020, and healthcare is costlier and more complex than ever. Constantly-changing policies, payment rules and quality measures are further muddying the waters at a time when transparency is fundamental to the sustainability of our healthcare programs.

Payment accuracy, or payment integrity, is the vital function that helps to protect organizations from fraud, waste and abuse by ensuring healthcare dollars are being properly allocated — and when they aren’t, that inaccurate payments are recovered back to the appropriate payer. As healthcare transitions away from outdated payment models and toward a more efficient, innovation-driven environment, so too must our systems for identifying, preventing and recovering these improper payments. And while big data, analytics and technology are a big part of the effort, they are, indeed, only part of the solution. Here are five key areas of focus in payment accuracy to help propel us into the next generation of healthcare.

1. Multidisciplinary Expertise: Clinical, Healthcare & Data Science

High-quality data, advanced analytics and automated technologies are quickly becoming the price of entry for payment accuracy solutions. But with the increasing volume and complexity of claims and healthcare data as a whole, specialized expertise is needed to understand how the data fits within the big picture and pursue measures that will create actual value for healthcare organizations. This requires a deep level of expertise spanning clinical practice, health information management, payer operations and government relations in order to adapt solutions to the needs of each program, plan and population.

2. Moving the Focus Upstream

Post-payment recovery will continue to play an important role in payment accuracy, but in order to capture the broadest scope of fraud, waste and abuse — and to cut down the time and resources it takes to do it — increasing focus must be placed on preventing inaccurate payments from occurring. The speed and accuracy necessary for successful pre-payment solutions that meet regulatory requirements demands a high level of expertise in predictive analytics and clinical reviews. This expertise can only be achieved by having access to large data sets, applying modern data science techniques and having experienced healthcare professionals to conduct reviews.

3. Building an Integrated Cost Control Engine

Payment accuracy is multifunctional — from fraud and abuse detection to auditing and quality monitoring. As such, it is becoming more important for organizations to adopt solutions that address all areas of payment and program integrity, including cost, quality and compliance. Managing these important healthcare functions in piecemeal form isn’t just inefficient — it’s counterproductive to the integrated and interoperable environment we’re working to create. With regard to payment accuracy, the ability to quickly and accurately identify billing errors both pre- and post-payment — across all claim types and various payment scenarios — requires a single-source, single-vendor approach for maximum efficiency and minimal risk.

4. Making Provider Engagement Part of Your Payment Accuracy Program

Because payment accuracy involves different stakeholders, solutions must prioritize user experience across the care continuum. Understanding the clinical workflow and developing technologies that integrate seamlessly into EHR systems helps to ensure providers are accurately paid for the services they deliver, without exacerbating already heavy administrative workloads. But beyond the technology, provider engagement is a vital component of an effective payment accuracy program. Examples include educating providers on best billing practices, helping to identify outdated policies and procedures, and facilitating positive, productive communication between payers and providers.

5. Don’t Go It Alone: Selecting an Experienced, Value-Driven Partner

Today more than ever, payment accuracy is far too complex and important a process to manage in-house or to stack disparate solutions. For the most value, healthcare organizations should look to comprehensive partners that maintain vast and high-quality data assets, incorporate new efficiency-enhancing technologies into their solutions, and leverage wide-ranging industry experience and institutional expertise to drive long-term value — with minimal stakeholder disruption.

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