Payment Integrity Payment Pressures
Deeper Dive into The Pulse of Payment Integrity
Foreword
CERIS partners with many health plans and has witnessed the evolution in digital delivery, payment processes and editing and auditing accuracy. As changes in payment processes continue, so do the payment pressures that impact payers and providers. In addition to the recurring payment accuracy issues affecting claims processes, post pandemic challenges have emerged to create new payment pressures.
The top 5 current payment pressure points we have seen include:
- Telehealth: the rapid growth of telehealth services have been a great thing, but they have also created new payment models to consider in a payment accuracy process. There is variability in telehealth services and coverage, so it can be a challenge to make sure payment is correct. Because services are no longer physically taking place in an office, it can also make it harder to verify the validity of services.
- Claim Process: There are increasing administrative burdens and changes in claim processes such as additional diagnosis around COVID-19, an increased difficulty in forecasting utilization, increased visits for therapies, hospital at home initiatives, excess in Rx prescription early refills and quantities, and difficulty assessing appropriate length of stays.
- Operations: The great resignation, silent quitting, and labor shortages can all exacerbate billing inaccuracies and an increase in payment errors. There are flex work schedules, remote billing staff, and a need to allocate resources in different areas.
- Regulatory: Transparency continues to be at the top of the priority list relating to federal government regulation as well as changing processes around surprise billing. There are also individual state mandates around claim reviews and non-essential claims processes that were created around COVID.
- VBC: Value-based care payment methodologies are already prevalent in government programs and increasingly in commercial programs. While this delivery model is a favorable trend impacting the quality of care rather than the volume of care, there are many different structures to these models that can impact payment integrity services. Payment integrity in the context of VBC is ensuring payments are made based on the agreement and accurately reflect the actual quality of care provided. It is a critical factor in the success of VBC because it ensures the right providers are rewarded for delivering quality outcomes
With these ever-changing challenges, people continue to innovate and payment integrity programs are the perfect place to mitigate these additional pressures. Improving your payment integrity program to address new disruptors requires increasing your payment integrity expertise. Now more than ever, payers are looking to partner with vendors to deliver the tools, techniques, and talent to support their internal programs.
This deeper dive article looks further into these challenges initially outlined in our Pulse on Payment Integrity white paper. We hope our in-depth analyses continue to provide tools to help you enhance payment integrity success.