Latest / Becker’s Payer Issues Podcast / Navigating Payer Compliance and Regulatory Oversight with Cereasa Horner of CERIS

Transcript

Navigating Payer Compliance and Regulatory Oversight with Cereasa Horner of CERIS · Becker’s Payer Issues Podcast

• 0:00
  Hi, everyone. This is Lucas Voss with Becker's
• 0:02
  Healthcare. Thanks so much for tuning in to
• 0:04
  the Becker's Healthcare podcast series. It's exciting to
• 0:07
  have you. And we're talking about an exciting
• 0:10
  topic that's seen a lot of movement lately,
• 0:12
  payer compliance
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  and regulatory oversight in health care. And I'm
• 0:16
  so excited to be joined by Sarisa Horner,
• 0:19
  director of policy and payment integrity at Saris.
• 0:23
  Sarisa, thanks so much for being here today
• 0:25
  and taking the time. Thank you for having
• 0:27
  me.
• 0:28
  It's great to have you. And I wanna
• 0:30
  start off with introductions for our audience. Could
• 0:32
  you introduce yourself and just share a little
• 0:34
  bit about your work in health care? Thank
• 0:37
  you so much. So my name is Theresa
• 0:38
  Warner. I'm the director of policy and payment
• 0:41
  integrity here at Saris. I've been with Saris
• 0:43
  a little bit over eight years, but actually
• 0:46
  in the health care industry around eighteen years.
• 0:50
  I started out in health care revenue cycle,
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  working for hospitals and really gaining a deep
• 0:55
  understanding
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  of what that revenue cycle process is from
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  beginning to end and then transition over to
• 1:02
  the payment integrity side,
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  working with vendors like Sarris who perform work
• 1:07
  on behalf of payers.
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  With Sarris, I actually oversee a few departments,
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  between provider relations,
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  recovery,
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  our internal QA,
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  and also policy review and implementation.
• 1:21
  And, Sarrisa, I feel like we need that
• 1:23
  deep understanding today because there's a lot of
• 1:26
  movement as I've mentioned. There's a lot of
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  things are happening,
• 1:30
  within the payer oversight space. Right? There's CMS
• 1:33
  ramping up Medicare Advantage audits to to states
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  issuing fines related to reimbursement
• 1:39
  practices and and mental health parity. There's so
• 1:41
  much happening right now. And I'm I'm just
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  curious from your perspective,
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  what are some of those most pressing challenges
• 1:47
  that you're seeing that health plans face and
• 1:49
  and adapting to that new scrutiny to all
• 1:52
  of that movement both on the federal and
• 1:54
  state levels?
• 1:56
  I'd say consistency.
• 1:59
  Yeah.
• 2:00
  You know? And I'd say that that's all
• 2:02
  the way around,
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  whether that's from state and federal guidance and
• 2:07
  implementation
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  to their own
• 2:10
  internal policies.
• 2:12
  It's very hard
• 2:13
  to be consistent across different states,
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  when it comes to specific guidelines, especially when
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  you think about,
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  something like mental health purity. Right?
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  I'm not sure quite how many people are
• 2:26
  familiar with it, but mental health purity basically
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  means that
• 2:30
  insurance plans have to treat
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  mental health and substance
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  use disorders
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  the same way that they would treat
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  any other condition
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  that a a patient may have.
• 2:43
  Yeah.
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  You know? And it's it's it's very hard.
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  You know, we would think that it's 2025,
• 2:49
  so all benefits would be treat be treated
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  equal.
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  But, unfortunately, that's not true. So different states
• 2:55
  have different guidelines when it comes to that.
• 2:58
  And they're basically trying to make sure that
• 3:01
  the co pays
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  and the deductibles,
• 3:05
  the number of of visits that are available
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  for services,
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  are the same. Right?
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  Even down to pre authorization,
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  making sure that if an authorization is not
• 3:16
  required
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  for a same or similar,
• 3:19
  physician health benefit or physician health service, that
• 3:23
  that mental health benefit
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  is treated in the same way.
• 3:27
  And you've mentioned,
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  again, consistency and how hard it is to
• 3:31
  maintain consistency, and it's it's crucial for success,
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  obviously. Now consistency becomes even even harder when
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  things get more complex, right, as we've talked
• 3:42
  about, and and when things become very dynamic
• 3:44
  because you have to change constantly. And again,
• 3:46
  that obviously impacts consistency there. What are some
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  of the strategies that you're seeing payers adopting
• 3:52
  right now to to keep up? Right? And
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  I was wondering if you'd also have any
• 3:56
  any sort of example of of tools or
• 3:59
  or examples of of your your work that
• 4:01
  stand out to you.
• 4:03
  Yeah. I would say that,
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  consistency is is is pretty
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  challenging because
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  most payers,
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  even most health systems,
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  and even vendors,
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  you have multiple systems that don't always talk
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  to each other. You know? And they are
• 4:20
  not always compatible
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  with each other. And so
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  it's really trying to be able to be
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  proactive
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  because that's what, you know, we're looking to
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  do when you are,
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  implementing different federal and state guidelines.
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  And there is a couple of different ways
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  to do that, but it does require everybody
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  working together,
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  and having a central vision,
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  and being
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  very clear
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  about what that end goal,
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  and the outcome is that we want to
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  have. So I would say first,
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  is that everyone kind of talks about AI.
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  And I think AI is very important,
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  when it comes to looking at at payment
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  integrity
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  and how data is viewed
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  and how data is collected
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  across different,
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  patient health groups. And so when you look
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  at something like risk adjustment,
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  CMS has really ramped up their audits on
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  that. And so how do payers actually
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  tackle that issue
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  because
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  negative impacts from those risk adjustment audits can
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  have very significant financial impact on a payer.
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  And sometimes it can be due,
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  to the smallest piece of,
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  documentation
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  either being missing or documented incorrectly.
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  And so one of the things that a
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  lot of payers do is that they work
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  with their internal teams. I like to call
• 5:51
  them cross functional,
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  where we're really making sure that
• 5:55
  different departments, whether that's claims or finance,
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  are really inputting the information
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  that's needed to get down to that granular
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  level,
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  that CMS will be looking for.
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  Yeah. And you've touched on a couple of
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  important things here. One, obviously, is being able
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  to eliminate silos and having conversations. I I
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  again, I love the cross functional piece, right,
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  that's so important for success today and being
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  proactive
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  and, again, AI, such a big piece of
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  the conversation as well.
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  What are some of those additional capabilities
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  or approaches that that you're looking towards for
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  the future here for for, obviously, the 2025,
• 6:34
  but 2026
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  as well that are really critical for payers
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  to look at as they're continuing to to
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  navigate the space? And and what's one thing
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  that that you think everybody should be doing
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  right now to be able to be prepared?
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  I think that everyone should be looking beyond
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  just traditional fraud, waste, and abuse.
• 6:53
  We all have
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  very comprehensive
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  systems
• 6:57
  for the most part that are able to
• 6:59
  track that. Now ideally, we would like for
• 7:02
  all of that to be done prepay,
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  and that's where the industry is trying to
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  move toward is having a lot of these
• 7:09
  audits that are conducted post pay
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  transition
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  to prepay reviews. It's a lot cleaner and
• 7:16
  it's a lot easier for both parties,
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  meaning the payer and also the provider.
• 7:21
  But we really have to look
• 7:24
  at our AI discussion and our, software discussion
• 7:30
  as being able to identify some predictive compliance
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  modeling. Right?
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  There are ways to use NLP
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  and machine learning
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  to make the review of records and policies
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  much more consistent in being able to identify,
• 7:48
  I say, anomalies in the data or areas
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  to focus on beyond just our traditional FWA.
• 7:55
  Yeah. As you pointed out earlier in the
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  conversation, this is something that never stands still.
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  There's it's always evolving. There's always something new
• 8:02
  happening. So it's really becomes critical to, as
• 8:04
  you've mentioned, be proactive and and looking at
• 8:07
  the tools that can make this better in
• 8:08
  the long run. Sarisa, again, thank you so
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  much for your time and insights today. I
• 8:12
  I wanted to open the floor up to
• 8:14
  you here as we close out our conversation.
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  Any fun final thoughts or anything that we
• 8:18
  didn't cover that you'd like to share with
• 8:20
  the audience?
• 8:21
  I would say, you know, look. It's just
• 8:23
  in general.
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  Compliance is no longer really about just checking
• 8:27
  the box. You know? For decades, we have
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  kinda just checked the box of just the
• 8:32
  standard things that we're looking for, whether that's
• 8:35
  timely filing, no authorization,
• 8:37
  met NEC. And as we are seeing with
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  the changes in federal guidance and even down
• 8:42
  to state guidance, we are seeing that reimbursement
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  when it comes to health care claims is
• 8:48
  a bit more fragile than what we have
• 8:50
  seen in the past. So it not only
• 8:53
  requires
• 8:54
  providers to be more agile,
• 8:56
  but also payers to be very agile.
• 8:59
  And one of the ways that I know
• 9:01
  that payers do is that they partner with
• 9:03
  vendors like Cirrus, where we're able to give
• 9:06
  them that industry knowledge, and we can actually
• 9:09
  discuss what does data transparency
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  actually look like. How do you become standard,
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  in the information that you're sending, and then
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  how do you tighten up those internal processes,
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  and make your reimbursement policies most effective and
• 9:24
  most in line with what your goals are.
• 9:26
  Yeah. Well, Theresa, again, thank you so much
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  for being here today. It's fantastic to have
• 9:30
  you. Thanks for your insights and your time.
• 9:33
  Thank you very much as well. And I
• 9:34
  feel like we'll have to revisit this at
• 9:36
  some point with everything that's happening. And we
• 9:38
  also want to thank our podcast sponsor, Cirrus.
• 9:40
  You can tune in to more podcasts from
• 9:42
  Becker's health care health care by visiting our
• 9:44
  podcast page at beccarshospitalreview.com.