Coordination of Benefits has a clear mission to maximize recoveries by identifying instances of other health insurance coverage. Subrogation maximizes recoveries by finding other parties responsible for the payment. Data Mining has a mission to identify overpayments, but the way the service finds the overpayments isn鈥檛 as clear cut as it is for Coordination of Benefits and Subrogation. Data Mining, a post-payment payment integrity service, detects errant medical claims in sets of data.鈥疎rrant claims typically include duplicate payments and claims with billing issues that lead to overpayments. 

Identifying and preventing overpayments

成人视频 identifies errant claims by scouring the data. We use artificial intelligence, including machine learning and algorithms, to identify incorrectly paid claims and anomalies in the data. We also have subject matter experts on our data mining team to review and confirm the findings of the technology. All findings are presented to our clients for approvals.

To help prevent the same type of overpayments from reoccurring, our Data Science team reviews the anomalies identified and determines which are the most important in terms of the overpayments they cause and whether action can be taken to correct and prevent them from reoccurring. If action can be taken, the team designs a programmable rule that can prevent the anomaly from occurring again. 

Finding overpayments others don鈥檛

Three of the country鈥檚 top five health plans use 成人视频鈥檚 Data Mining service. Collectively, 成人视频鈥檚 Data Mining service has identified over $145 million in commercial overpayments for these clients. What makes that number even more impressive is that typically our clients and other data mining vendors searched for overpayments before we had our turn. For one of these clients, we reviewed the data after six others had, and we still found overpayments. This means other vendors miss things we find. It also means we have to think outside the box when reviewing clients鈥� data.

Here鈥檚 what we find

The following are examples of overpayments 成人视频鈥檚 Data Mining team has found in our clients鈥� data:

• According to one of our client鈥檚 systems, a provider鈥檚 contract contained atypical language stating the provider would be paid a per diem of $3,000 for a service that lasted longer than one day. 成人视频 pulled the paper contract and confirmed the per diem clause was intended only for extremely rare cases. We obtained the client鈥檚 permission to expand the recovery period from one to two years and were able to identify 306 claims that were paid incorrectly, amounting to approximately $4 million in recoveries for overpayments.
  
  
• A national large insurer contracted with a high cost drug provider for 10% of charges and a 90% discount. However, the client鈥檚 system was programmed wrong, and they were paying 90% of charges with a 10% discount. The client was able to recover approximately $1.5 million from 17 incorrectly paid claims. 
  
  
• Our client鈥檚 contract with a provider stipulated the provider was entitled to 100% of billed charges (less denied claim lines) if their exclusions didn鈥檛 hit the contracted threshold. To sidestep the stipulation, the provider filed claims individually that should have been filed together so that the threshold wasn鈥檛 reached and the provider received 100% of billed charges. By identifying this, we helped our client recover approximately $1.7 million on 213 claims. 

Let us take a look at your data. You might be surprised by what we find. Learn more.

• Valuable: Lead to identification of overpayments
• Actionable: Result in an action that can be taken to correct the problem and prevent a future reoccurrence
• Explainable: Can be explained to clients and providers

An example of an anomaly identified is a single patient receiving thirty injections of the same vaccine, resulting in a charge over $30,000.

How anomaly detection works

Working with our data mining team, we use statistical machine-learning methods to identify anomalies in the data. Our experts then review the anomalies identified and determine which are the most important in terms of the overpayments they cause and whether action can be taken to correct and prevent them from reoccurring. Next, the team helps to design a programmable rule that can prevent the anomaly from occurring again. In the vaccine example above, for instance, the rule could be: a single patient cannot receive more than one shot of the same vaccine on the same day. And finally, the team keeps an eye on that rule after implementing it.

Anomaly detection works hand-in-hand with rules based concept development

Our outlier anomaly detection complements the rules-based concept development we already employ within our Payment Integrity services. With rules-based concepts, we rely on our expertise, experience and information we read or learn to program rules-based concepts into our systems. These are rules based on what we know shouldn鈥檛 happen, for example, two codes that shouldn鈥檛 be billed together.  In short, we have an idea, we code for it and then see the value.

In contrast, the concepts we program from our anomaly detection findings are based on oddities we identify in the data. In these cases, the data, not our experience, tells us what needs to be programmed. Additionally, unlike with rules-based concepts, we already have an idea of the value.

The two approaches complement each other.

Anomaly detection leads to more savings for 成人视频鈥檚 Payment Integrity services

To date, every client for whom we have run data through the model has experienced incremental savings.

Learn about 成人视频鈥檚 Payment and Revenue Integrity services here.

Without question, the single greatest challenge facing the U.S. healthcare system is rising costs. The U.S. spent a staggering  in 2019, the latest year for which federal data is available. Despite a massive undertaking by the industry to drive efficiency, healthcare trends show that spending continues to soar. With an average annual growth rate of 5.4%, the  predicts that by 2028 healthcare spending will reach $6.2 trillion, nearly 20% of our GDP. 

Fueled by the proliferation of chronic illness, our aging population, rising health wages, and the growing complexity of the healthcare system, U.S. spending outsizes and outpaces all other nations. Yet even with the greatest investment in healthcare, America  when it comes to health outcomes. We are facing a true cost crisis that impacts all players in the healthcare ecosystem. Consumers are paying more than they can afford, employers and the U.S. government are struggling to keep pace with rising costs, and both payors and providers are seeing profits squeezed. Our spending trajectory is no longer sustainable and must be better aligned to improve health outcomes. 

Short of overhauling the entire health system which is practically impossible, there is no easy solution or silver bullet to curtail rising costs. Instead, it will take a combination of forces chipping away at the margins to make healthcare more affordable. Here are five trends we鈥檙e watching in 2022 with the potential to lower costs, improve outcomes, and make our health system more sustainable over time. 

#1: The Consumerization of Healthcare Will Drive Down Costs

Until recently, healthcare has been immune to the forces of consumerism that have disrupted every other major industry. Catering primarily to payors and employers who have largely covered the cost of care, providers haven鈥檛 had to compete directly for consumers based on price and outcomes. But as consumers take on a far greater share of the cost burden, that is about to change. 

Out-of-pocket costs for healthcare have grown substantially, from higher premiums and deductibles to more expensive drugs. With increased skin in the game and digital expectations shaped by their experiences with other industries, a new generation of health consumers are bringing higher expectations for convenient, affordable, quality care on their terms. They want greater price transparency, better digital tools, and the ability to get care when and where they want it. In fact, the  shows consumers will increasingly choose medical providers who offer digital capabilities. This healthcare trend has only been accelerated by the pandemic, which quickly acclimated patients to virtual care platforms, digital communications, and new convenient care settings. 

Not only are consumers demanding more from the healthcare system, but they are also taking a more active role in managing their own health. In fact, a recent study from Wolters Kluwer Health shows 86% of consumers believe proactivity on their part is critical in ensuring high-quality care and outcomes. These empowered, price-conscious, digitally savvy patients will transform the future of healthcare as the industry innovates and adapts to deliver more patient-centric experiences. We expect this disruption will drive spending downward as providers compete more aggressively for patient loyalty and lower-cost delivery models emerge. Moreover, as patients take a more active role in their health, cost savings can be achieved through a healthier population. 

While the greatest impact of consumerization will initially be felt in the self-pay market, payors and providers must act now to align their experience to the expectations and needs of the next generation of health consumers. Taking a more patient-centric approach now means being more competitive now and in the future. 

#2: New Transparency Measures Will Put Pressure on Pricing

Given the cost of care and Americans鈥� increasing financial worries over health-related bills, it鈥檚 not surprising most want to know what they will pay before receiving care (just as they do for every other service they purchase). A recent  found 75% of patients now seek cost information before receiving care. Unfortunately, until now, that data has not been easy to find. Medical costs vary widely by location, provider, and coverage type, making it difficult for patients to understand their true costs and to comparison shop. 

Sweeping bi-partisan healthcare reforms aim to change that in 2022. In an effort to make healthcare more affordable, lawmakers are banking on a series of new transparency regulations to drive down costs by arming consumers with better pricing information. Reform measures including the , the , and the  make it easier for consumers to understand how much they will pay, compare costs, and make smarter provider selections. 

Despite significant industry hurdles to adopt these new transparency measures, widely available pricing information is expected to drive competition between providers and give patients the necessary resources to manage health costs proactively. 

Payors must act fast to ensure they are ready to comply with these new measures. It will also be essential to engage members in the adoption of pricing tools as they become available. While regulation will make more data available, it is unlikely to move the needle on the cost of care if consumers don鈥檛 use the information to make better spending decisions. 

#3: Cost Management and Payment Accuracy Innovations Will Cut Wasteful Spending

Waste is one of the most significant contributors to the high cost of healthcare, accounting for 20 to 30 percent of all spending. Fraud, abuse, and billing inaccuracies significantly drive up the cost of care, but new efforts and innovations in artificial intelligence and machine learning could turn the tide on this healthcare trend if they are widely adopted. Using advanced data and analytics to fuel negotiations, prevent and detect fraud, and manage claims, 成人视频 alone drove nearly $20 billion in savings for our customers last year. 

We expect to see the adoption of new cost management strategies accelerate in 2022, especially in using AI to curb administrative waste. While the benefits of AI are clear, the healthcare industry still lags behind the curve, with only . Bullish on its potential, leaders across healthcare are stepping up to accelerate their efforts, investing in new technology, partners, and staff that can leverage data and analytics to solve their most pressing cost challenges. In fact,  in AI in the last year. 

AI, machine learning, and advanced analytics also can fight one of the industry鈥檚 biggest cost management challenges – perception. For too long, cost management has been viewed as a negative practice, putting members, payors, and providers at odds with each other, when in fact, it is an essential solution to keep healthcare affordable. Through the use of predictive analytics, much of the abrasion that came along with traditional payment integrity solutions can be avoided. Advanced pricing data can be used to determine fair and reasonable rates that are a win for providers, payors and patients. 

As payors look to maintain profitability without raising premiums, proactive member engagement, member wellness initiatives, and effective utilization management should be a critical piece of any strategy to fight rising industry costs. Cost management is imperative to making our health system sustainable, and when done correctly, can actually lead to better health. It鈥檚 time for it to be seen as a positive force instead of a deterrent to quality care.

#4: Lower Cost Care Models Will Proliferate

Battered by high costs, it鈥檚 no surprise employers, the federal government, and consumers are looking for new healthcare options and are experimenting with a host of new payment models, care delivery channels, and innovations they hope will improve care and make it more affordable. With a focus on well-being, new care models are emerging and quickly transforming the future of healthcare as we know it. Where 80% of today鈥檚 health spending goes toward care and treatment, it鈥檚 estimated that by 2040,  and well-being, and the market is quickly shifting in that direction. 

Just as they were a driver of our current health system, employers looking to maintain a healthy and productive workforce are key drivers of this change. Facing , employers are finding alternatives to traditional health plans, encouraging the adoption of wellness programs, steering employees to lower-cost options and centers of excellence, and in some cases, even entering into the healthcare business directly to provide employees convenient and affordable options. Onsite clinics, fitness programs, and a greater emphasis on mental well-being are all on the table. As it foots the bill for aging populations and increasing numbers of Americans not covered by employers, the federal government is also putting more emphasis than ever on keeping patients well, resulting in the widespread adoption of value-based care. 

With so much on the line, healthcare incumbents, as well as new market disruptors, are rushing to bring new solutions to the market. In addition to new payment models, we are seeing widespread shifts in how and where care is delivered. Telehealth, which catapulted into the spotlight as a result of the pandemic, is here to stay as an efficient and effective delivery channel. Retail clinics and quick care centers are replacing traditional medical offices and giving consumers the convenience they want at a lower price tag. And direct-to-consumer offerings are taking off, giving consumers affordable access to address common health needs from birth control to mental health. Even hospitals are taking a back seat, increasingly used only as a last resort for urgent health needs. Care will be decentralized, and patients, previously hospitalized, will increasingly be cared for from home. 

With demands for more affordable plans, payors will continue to adapt and embrace new models, innovating new reimbursement strategies that support a transition from a fee-for-service system to a model that rewards total wellness. Working closely with providers, payors will need to redefine the value of care and effective reimbursement strategies that reward and incent for healthy patients. Plans that continue to elevate the member experience, engage members in wellness programs, embrace new care delivery options, and offer more flexible, affordable networks, will be well-positioned to succeed in this rapidly changing environment. 

#5: Greater Collaboration Will Drive Efficiencies Throughout the System

Our healthcare system faces vast challenges in the years ahead. Delivering efficient, affordable solutions to meet increases in the demand for care, produce better patient outcomes, rise to new consumer expectations, and create fairness for all parties – patients, payors, and providers – is a tall order. However, a movement toward greater collaboration between all players could help pave the way, and we are starting to see signs that it is underway. Changes in care delivery models, greater interoperability, the digitization of healthcare, and more engaged consumers are fostering an era of collaboration not previously seen, in which patients, their providers, and their health plans all work together to improve outcomes and lower costs. 

A shift to value-based care models is accelerating this healthcare trend. As payment becomes intertwined with patient outcomes and satisfaction, we continue to move away from a transactional model toward a patient-centric system of care in which providers and payors share an interest in keeping patients healthy. The movement will drive better coordination between providers as they are incented to work together to proactively manage patients’ overall well-being, resulting in the more efficient and effective use of our healthcare dollars.

Once a roadblock to collaboration, technology platforms will also transform how the industry works together to deliver the future of care. 2022 will bring continued innovation and investment to build platforms and solutions that improve workflows, break-down silos, and drive efficiency through collaboration. Though much still needs to be done, improved interoperability allows care teams to see the complete picture and reduce duplicate or unnecessary procedures. In addition, increased digitization empowers patients to take a more active role in managing their care. With the proliferation of electronic medical records, patient portals, apps, and digital health tracking tools, it is easier than ever for patients to communicate with their providers and share information across their care teams. 

Collaboration is the only way forward if we are to bring necessary cost savings to our health system. Payors have a key role to play and will need to work closely with providers toward shared goals that benefit patient outcomes and increase efficiency. While several new regulations will force deeper collaboration between payors and providers, those that can proactively seek collaborative partnerships with their provider networks and members will be better positioned to reap the benefits, driving bottom line savings through reduced administrative costs and improved patient outcomes.

At 成人视频, our mission is to make healthcare more efficient, affordable, and fair. While there are no easy answers to tackle the mounting cost challenges facing our industry, we are eager to see how each of these healthcare trends contributes to a more sustainable future in 2022 and beyond. We鈥檒l continue to do our part, working with our partners across the industry to inspire change and innovate new cost-saving solutions. 

Contact us today to learn more about what these healthcare trends mean for your business and how 成人视频 can help you adopt cost-saving strategies in 2022. 

What makes 成人视频 a successful partner and what are we doing differently to support our clients鈥� success?

成人视频 has built a solid reputation for providing value to health plans by helping to solve their payment integrity challenges. We owe our success to our exceptional people and culture of accountability. Every employee across the organization understands the importance of their role and how they contribute to our clients鈥� success. The whole organization can be seen working tirelessly to anticipate customers鈥� needs and earn their trust.

Communication is a big part of our approach to account management at 成人视频. We talk to clients frequently as well as conduct client surveys to hear directly from our clients on how we鈥檙e doing and how we can continue to provide profound value to our clients鈥� organizations.

Through this hands-on approach, we鈥檝e learned that we do many things right. Clients especially appreciate how we advise them to determine the best course of action for their operations and provide timely follow-up to address their concerns. This valuable feedback also helps us identify opportunities where we can improve our processes and solutions to better meet clients鈥� needs.

In addition, we have a Client Council that brings together individuals across our client base whose voices influence the future of our business. We host in-person and virtual meetings with our Client Council to deepen relationships and understand what clients need to be successful. These meetings not only provide clients with valuable networking opportunities, but also offers clients opportunities to share insights and best practices with other health plan leaders and drive future innovations.

What is 成人视频鈥檚 approach to account management, and how do we drive value throughout the entire engagement with a client?

Our approach is flexible to meet each client鈥檚 unique needs, but it always starts with earning their trust, by getting to know them and understanding their business operations. We listen closely to their concerns and create a plan to provide payment integrity support that addresses their challenges and aligns with their strategy and priorities.

When clients join 成人视频, we put together an implementation team with the right skills and specific expertise to ensure a smooth, accurate, and efficient implementation. Our approach is flexible and can wrap around or come behind existing vendors and processes already in place. 成人视频鈥檚 multi-disciplinary teams work collaboratively and our experts evaluate each client individually. There is no one-size-fits-all approach.

Once implementation is completed, an internal hand-off to the Account Management team occurs and all unique attributes and needs for each client are discussed in detail. A dedicated account manager takes the lead to provide guidance and manage day-to-day activities and communicate the status of ongoing projects every step of the way. We don鈥檛 just hand over reports; we take time to meet regularly with clients to review their information in a way that鈥檚 meaningful so we can make recommendations for improvements and achieve their desired results.

What are some of the ways 成人视频 helps health plans address unexpected payment integrity challenges like the COVID-19 pandemic?

COVID-19 is unlike any event the healthcare industry has seen in modern times, thus health plans are faced with challenges they could not have imagined. Not only do health plans need to ensure their members receive the care they need and support their providers, health plans must also keep up with individual states鈥� mandates regarding 鈥渘on-essential鈥� claims processes and review of COVID-19 related claims. At the same time, they are struggling with reallocating resources to support critical COVID-19 initiatives while managing the shift to a remote workforce.

成人视频 is proactively reaching out to clients to make recommendations, based on their business, to help protect premium revenue, pick up productivity shortfalls as needed, and help them protect their workforce. We continue to work diligently on behalf of our clients as an extension of their teams to ensure they get the right information to support the continuity of their payment integrity operations.

A year prior to the COVID-19 pandemic, our payment integrity operations went remote, putting us in a great position to help support our clients鈥� business during the pandemic. 成人视频 views challenges as an opportunity to learn from individual clients鈥� needs. As COVID-19 plays out, we will continue to partner with clients to make sure we are supporting them and their challenges are addressed in a timely manner.

Learn more about how 成人视频鈥檚 Payment and Revenue Integrity 成人视频 can help you restore and protect your premium dollars, potentially adding millions to your bottom line.

Previously published on the former Discovery Health Partners website.

Part of this administrative burden stems from a complex claims adjudication process impacted by legacy or outdated technology, a lack of clear contract or policy information, and no universal way for sharing information (e.g., member鈥檚 name, diagnosis code, etc.). These administrative challenges results in data and eligibility errors that are made throughout the claims continuum, resulting in millions of dollars in improper payments.

Life of a claim: Errors along the way

Despite the best efforts to address waste, administrative complexity in the healthcare system continues. Recent research from JAMA shows that measures to eliminate healthcare waste would result in a 25% improvement, but there鈥檚 more work to be done. Finding the root causes of errors is the most effective way to ultimately remove waste鈥攁nd the high cost of it鈥攆rom health plans鈥� payment integrity operations.

Here are three approaches to combatting the high cost of waste in your payment integrity strategy.

1. Reduce manual processes

Manual processes are often at the heart of human error. Manual processes are tedious, error-prone, and inefficient, contributing to the high cost of waste in healthcare. When your entire claims adjudication or payment integrity process contains manual tasks, the likelihood of error is high. Reducing or eliminating manual effort in your payment integrity processes will go a long way toward reducing waste.

2. Use technology to your advantage

Technology plays a key role in taking out waste from the payment integrity process. But outdated or legacy technology can create just as much waste as you might find with manual processes. With the right technology in place, you can modernize your payment integrity processes and reduce the amount of time and effort associated with correcting complex claims.

By the same token, emerging technologies like artificial intelligence and machine learning solve traditional payment integrity problems in new and innovative ways. These technologies offer analytics and predictive insights that can optimize your claims payment processes and drive data-driven decisions.

3. Look to a partner for advanced capabilities

A partner can supplement your in-house operations and offer the expertise you need to reduce waste. The right partner will bring robust capabilities that round out your core operations鈥攃apabilities like data mining techniques that prevent incorrect and unnecessary payments; industry experts who are up on the ever-changing and complex healthcare landscape; and processes that identify opportunities to correct, recover, and prevent improper payments at all points in the claims鈥� lifecycle.

The high cost of waste can threaten the viability of organizations throughout the healthcare ecosystem. With a holistic, connected payment integrity strategy built around these three tenets, your organization can improve operational efficiencies and achieve financial integrity by preventing improper payments鈥攁ll while eliminating waste and generating meaningful results.

To learn how 成人视频 can help you advance into the future of payment integrity, contact us today.

¹ 鈥淲aste in the US Health Care System: Estimate Costs and Potential for Savings,鈥� JAMA, October 7, 2019.

Previously published on the former Discovery Health Partners website.

When eligibility errors occur, they affect many payment integrity areas such as coordination of benefits (COB), subrogation, and Medicare secondary payer (MSP) validation. Failing to address these issues leads to incorrectly paid claims, improper reimbursements, or claims that shouldn鈥檛 be paid at all鈥攃osting your health plan millions.

This infographic identifies the top three causes of eligibility errors and illustrates how a connected payment integrity approach can help.

Interested in learning more about eligibility data and how a connected payment integrity approach can help? Contact us today!

Previously published on the former Discovery Health Partners website.

5 key data analytics roles necessary for creating analytics that will drive value for your organization

Data Liaison

The person in this critical role is someone who really understands your business goals鈥攁nd can straddle the discussion between business and data. They participate in discussions with your business around your real-world problems and understand enough of the health claims data to realize when a particular problem might be something that can be addressed with the data you can access. In fact, this person is so familiar with your business they might even be able to generate their own list of real-world problems you face that could be addressed with available data knowledge.

Data Architect

This key technical leadership position understands your big picture鈥攖hey know what data you have, where it is, and how it fits together. They are current in their understanding of data technologies and can apply that knowledge to your organization鈥檚 health plans on how it will leverage data. They help create the blueprint for the environment(s) you need for data science and analytics.

Platform Architect

Many organizations don鈥檛 have member and health claims data set up in a way that鈥檚 really conducive to analytics or big queries. In this IT role, your platform architect will work closely with the analytics team to create the infrastructure needed for effective analytics. They are the person who makes sure your organization has enough 鈥渉orsepower鈥� for the job at hand.

Data Analyst

As the extractor of data, this is the person you鈥檙e most likely to already have in your organization. The data analyst is often your go-to person for analyzing data sets and reporting results. The data analyst understands SQL, SAS statistical software, and your business goals to manipulate healthcare databases and produce analytic findings.

Data Scientist

For more advanced analytics against your data sets, the data scientist works to understand real-world problems and writes the models. They work with big data, using various technologies to develop models that convert data into actionable insights. They may also help identify new data sources and work with the data and platform architects to fuse them with other enterprise data sources. This role collaborates with the data analyst to get access to usable member data and works with the data liaison to understand what the real-world problem is and build the models that ultimately help drive your value.

You don鈥檛 necessarily need five people to fulfill these functions since some of these data analytics roles can be combined. You may have an organization where your data analyst and data liaison roles are filled by the same person, or one person may serve as both data and platform architect. The key is to understand that you鈥檙e checking each of these boxes so your company is able to take a singular real-world problem and help turn it into the model that鈥檚 going to help drive value.

Learn more about how 成人视频鈥檚 Data Mining Service can help you restore and protect your premium dollars, potentially adding millions to your bottom line.

Previously published on the former Discovery Health Partners website.