Five Strategies to Maintain, Yet Balance, Program Integrity During the COVID-19 Pandemic

March 26, 2020 HMS

Amid the chaos of a global health crisis, program integrity is vital to maintaining the healthcare safety net, while protecting healthcare organizations from fraud, waste and abuse (FWA). As new codes are developed and patient loads intensify, payers may become increasingly susceptible to fraud schemes and unintentional waste, putting both patients and the system at risk. But with providers stretched thinner than ever, payers must be careful to uphold program integrity practices while not exacerbating provider burden.

Here are five recommendations to help you protect your organization from FWA while supporting your provider network through this challenging time.


  1. Institute Prospective Reviews for Payment Accuracy

Cutting down on the administrative workload that comes with claims rework and pay and chase should be a priority for payers in today’s tumultuous healthcare environment. Implementing pre-payment systems helps to ensure right-first-time billing and prompt payment, while avoiding the inherently difficult position of coming from behind to recover improper payments. In addition to reducing the need for post-payment audits, pre-payment reviews can also serve as a viable alternative to prior authorizations — a significant source of administrative burden for providers.

  1. Consider Shifting from Prior Authorizations to Notifications of Service

Prior authorizations may be a notoriously burdensome process for providers, but they play an important role in ensuring patients receive the right care, at the right time, in the right setting. As providers focus their efforts on patients most in need of urgent care, shifting to a notification of service model can help alleviate the prior authorization workload and ensure patients receive prompt access to vital healthcare services. Once the COVID-19 pandemic has subsided, auditing these claims against medical records can identify opportunities to recover improper payments. But now more than ever, ensuring providers are equipped to deliver timely, effective care must remain the number one priority.

  1. Factor Buffers, Extensions into Your Timelines

While exact measures will vary based on the specifications of your program and provider network, delays and extensions will be inevitable across the board. Evaluate timelines around activities like documentation requests, denials and appeals, then consider granting an extension and/or buffer to accommodate for an influx in workload. If you haven’t already, enabling electronic document transmission can help streamline the request and response process, reducing paperwork for both payer and provider.

  1. Be a Partner — We’re All in This Together

Payers, providers and industry partners must work collectively to protect the sustainability of our nation’s healthcare programs amid this global crisis — and acting with transparency and compassion can go a long way. Rather than just issuing technical denial letters, for example, consider first notifying providers with a phone call. Not only does this let them know what to expect, but it gives you the opportunity to engage at a time when communication is critical. By way of a strong partnership, rethink audit strategies. For example, ask whether a desk audit be as effective as an onsite audit. During this time of uncertainty, it’s especially important to avoid blanket approaches where possible.

  1. Know That Change Is Inevitable, and Be Flexible in Adapting to It

As we’ve experienced from the onset of COVID-19, guidelines and conditions can change by the hour. We are in the midst of an unprecedented global event and are developing the tools to combat it in real time. HMS’ clinical and payment integrity experts are maintaining a close pulse on the information coming from government agencies, and we will continue to advise you on current best practices and support you through this time of change and uncertainty.


For more tips on maintaining program integrity during the COVID-19 pandemic, download our full Program Integrity in a Pandemic guide.

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