Latest / Becker’s Payer Issues Podcast / What Health Plans Need to Know About the Next Regulatory Pivot

Transcript

What Health Plans Need to Know About the Next Regulatory Pivot · 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
• 0:03
  - the Becker's Healthcare podcast series.
• 0:06
  - It's great to have you. Today, we're talking
• 0:08
  - about what health plans need to know
• 0:10
  - about the next regulatory
• 0:12
  - pivot.
• 0:13
  - And joining me for today's pivot is Sarissa
• 0:17
  - Horner. She's the vice president of payment integrity
• 0:19
  - and governance at Sirris. Sarissa, it's so great
• 0:22
  - to have you. Thanks so much for being
• 0:23
  - here. Well, thank you for having me, Lucas.
• 0:25
  - I greatly appreciate your time today. It's great
• 0:27
  - to have you. I do wanna start us
• 0:29
  - off with introductions for those that might not
• 0:31
  - know you or Sirius.
• 0:33
  - If you just if you could just introduce
• 0:34
  - yourself to share a little bit about your
• 0:36
  - work in health care. Oh, absolutely.
• 0:39
  - So recently transitioned from the director
• 0:41
  - of policy and payment integrity
• 0:43
  - role into the vice president of payment integrity
• 0:45
  - and governance role here at Saris. I've been
• 0:48
  - with the organization almost nine years, but I've
• 0:51
  - actually been in health care,
• 0:53
  - revenue or payment integrity for almost the last
• 0:55
  - twenty years, which is crazy to be able
• 0:59
  - to say.
• 0:59
  - But I really had the opportunity to see
• 1:02
  - how the industry has evolved firsthand.
• 1:05
  - And we'll touch on that a little bit
• 1:07
  - here, because it's an important part of this
• 1:09
  - conversation, especially how it's evolved. I do wanna
• 1:12
  - start us off with a little bit of
• 1:14
  - a captain obvious statement here.
• 1:16
  - We know that
• 1:17
  - regulatory change historically
• 1:20
  - has moved very slow. I think everybody knows
• 1:23
  - that. Yeah.
• 1:24
  - Again,
• 1:25
  - I feel like that pace, though, especially over
• 1:28
  - the last couple of years, has
• 1:30
  - accelerated tremendously for payers. Again, the challenge now
• 1:33
  - becomes, okay. We need to adapt quickly,
• 1:37
  - again, without creating confusion or friction for providers.
• 1:40
  - Emit
• 1:42
  - that quick changing environment.
• 1:44
  - How from your perspective, how is this volatility
• 1:47
  - reshaping payment integrity strategies, and what are some
• 1:50
  - of the strongest plans doing
• 1:52
  - to keep providers aligned with this shift?
• 1:57
  - You know, the the pace of that regulatory
• 2:00
  - change
• 2:00
  - is really requiring
• 2:02
  - PI programs to be far more agile than
• 2:05
  - they were even a few years ago,
• 2:07
  - throughout the pandemic. You know, we were all
• 2:09
  - kinda scrambling to figure out what was next,
• 2:11
  - how do you implement it,
• 2:13
  - and and how do we work with providers
• 2:15
  - proactively.
• 2:17
  - But but this changes
• 2:19
  - quite a bit different,
• 2:20
  - because, again, historically, organizations have had time to
• 2:24
  - interpret guidance.
• 2:26
  - They've had time to build workflows,
• 2:28
  - have conversations, and educate their providers
• 2:31
  - before any of these major changes happen
• 2:34
  - that impact reimbursement
• 2:36
  - on both sides.
• 2:38
  - It it's not just on the providers.
• 2:40
  - And so with the pace of the change
• 2:42
  - now, that timeline has really shortened
• 2:45
  - significantly.
• 2:47
  - So what we see is that some of
• 2:48
  - the strongest health plans or the plans that
• 2:51
  - have more mature programs
• 2:53
  - are really moving from being reactive,
• 2:56
  - into more
• 2:57
  - continuous,
• 2:59
  - monitoring
• 3:00
  - of regulatory changes and how they model that.
• 3:02
  - Right?
• 3:03
  - They are really
• 3:05
  - building and investing in cross functional teams,
• 3:08
  - which I think is something that has traditionally
• 3:11
  - been a nice to have
• 3:14
  - for a lot of plans, but now it
• 3:16
  - is really a requirement.
• 3:17
  - You have to bring together not only your
• 3:19
  - payment integrity team, but your compliance,
• 3:23
  - legal,
• 3:24
  - network, provider relations,
• 3:26
  - and even your operations team to make sure
• 3:29
  - that everyone is on one accord with the
• 3:32
  - regulatory
• 3:33
  - changes. Because as we know, when you make
• 3:35
  - a change in one in one space, you
• 3:38
  - have to make sure that that flows downstream
• 3:40
  - and then all the appropriate teams have all
• 3:42
  - the necessary information
• 3:44
  - to just make sure that things flow,
• 3:46
  - as smoothly as possible.
• 3:48
  - With that, you wanna make sure that they're
• 3:50
  - really prioritizing
• 3:52
  - all communication,
• 3:55
  - internally and externally.
• 3:57
  - That could be putting notices
• 3:59
  - on their websites,
• 4:01
  - sending out,
• 4:03
  - a series of provider education emails so that
• 4:05
  - you're really exhausting every avenue to make sure
• 4:08
  - that everyone is educated
• 4:10
  - about what the change is and how that
• 4:13
  - change impacts them.
• 4:15
  - When you're thinking about all of these changes,
• 4:18
  - again, there's so much happening when we're looking
• 4:19
  - at the regulatory landscape here, for 2027 beyond,
• 4:23
  - etcetera.
• 4:23
  - Are you looking at specific updates
• 4:26
  - from CMS or Medicaid that are
• 4:29
  - most likely to create more of this sort
• 4:32
  - of friction that you've touched on?
• 4:35
  - Yeah. So I would say that a large
• 4:37
  - part of the friction
• 4:39
  - is going to be in documentation
• 4:42
  - because there's an increased focus on
• 4:46
  - providers making sure that the documentation is present
• 4:49
  - for everything in their medical record, but also
• 4:51
  - an increased responsibility
• 4:53
  - on payers to make sure that their policies
• 4:56
  - reflect
• 4:56
  - the requirements
• 4:58
  - for the documentation.
• 4:59
  - And that can become a bit challenging because
• 5:02
  - when you're working with, you know, medical necessity
• 5:04
  - or risk adjustments and things like that, you
• 5:07
  - have
• 5:08
  - CMS federal guidelines, but then you also have
• 5:11
  - state guidelines. Right? And plans are trying to
• 5:14
  - figure out, okay, well, how do we land
• 5:16
  - in the middle to where we are following,
• 5:19
  - federal guidelines, but then also following those state
• 5:22
  - guidelines,
• 5:23
  - making sure that the programming,
• 5:25
  - for claims adjudication
• 5:26
  - is actually correct, and it's firing on all
• 5:29
  - cylinders appropriately because that can also turn into
• 5:33
  - having provider abrasion as well. So I would
• 5:36
  - say, you know, with CMS's increased focus
• 5:39
  - on risk adjustment,
• 5:41
  - you really have to understand
• 5:43
  - how you're capturing the data, not just AI,
• 5:47
  - capturing the notes from those encounters,
• 5:50
  - but making sure that that information is truly
• 5:52
  - captures,
• 5:53
  - what is happening.
• 5:55
  - I wanna talk a little bit more about
• 5:56
  - that documentation piece and and specifically the data
• 5:59
  - that you mentioned too because there's there's sort
• 6:01
  - of a mismatch that's been happening. CMS is
• 6:03
  - working through a multiyear backlog
• 6:06
  - as of today of audits spanning from 2018
• 6:09
  - to 2021. So this is a tremendous
• 6:12
  - amount of documentation.
• 6:14
  - Again, there's
• 6:15
  - a lot of errors being surfaced today. They
• 6:18
  - stem from these documentation gaps that were never
• 6:21
  - really addressed, unfortunately.
• 6:22
  - When we're looking at all of this, when
• 6:24
  - we're looking at that, documentation gap, how should
• 6:27
  - plans approach those that legacy cleanup, right, stuff
• 6:31
  - that it's been there forever
• 6:32
  - in a way that brings providers along as
• 6:35
  - partners rather than sort of telling them that
• 6:38
  - they're the problem in this?
• 6:40
  - Yeah. I think it's important to recognize that,
• 6:43
  - you know, many of these documentation
• 6:45
  - issues
• 6:46
  - originated during a period of extraordinary disruption
• 6:50
  - during the pandemic. Right? You know, providers were
• 6:53
  - really focused on maintaining access to care, providing,
• 6:57
  - care to patients
• 6:59
  - when things were rapidly changing then. So there
• 7:01
  - are a lot of, I'd say, gaps
• 7:03
  - to to backfill just from that and lessons
• 7:06
  - learned. But when they're approaching, you know, these
• 7:08
  - legacy reviews,
• 7:10
  - the conversation really should begin with shared accountability.
• 7:13
  - You know, you can't be successful in kinda
• 7:15
  - pointing fingers at each other. So the focus
• 7:18
  - should really be on understanding what happened,
• 7:21
  - identifying what the root causes are. Are those
• 7:24
  - things still happening within the organization?
• 7:28
  - If they are, how do we address that
• 7:30
  - collaboratively
• 7:31
  - across teams, not just hanging that responsibility
• 7:35
  - on one individual
• 7:36
  - or one team? Right?
• 7:39
  - I also think that a lot of the
• 7:42
  - more effective organizations,
• 7:44
  - they find educational opportunities,
• 7:46
  - whether that's sharing data or trends in data.
• 7:50
  - And and I will say when you're looking
• 7:52
  - at data, getting on one accord
• 7:54
  - with the type of data that you're looking
• 7:56
  - at,
• 7:57
  - what story is the data actually telling? Because
• 8:00
  - there could be multiple instances where there may
• 8:03
  - be lots of different things to address from
• 8:05
  - different perspectives.
• 8:07
  - That's where those cross functional come teams come
• 8:10
  - in because everyone comes with a different perspective
• 8:12
  - and has,
• 8:13
  - a different eye.
• 8:15
  - I'd also say that
• 8:17
  - you know, what I also find is that
• 8:19
  - when changes like this occur,
• 8:22
  - transparency
• 8:23
  - is
• 8:24
  - is key.
• 8:26
  - You will not have success without having that
• 8:28
  - internal
• 8:29
  - transparency
• 8:30
  - and external transparency.
• 8:32
  - Providers are more likely to engage more constructively
• 8:36
  - when they can understand how the decisions are
• 8:38
  - being made,
• 8:39
  - how you're identifying your findings,
• 8:42
  - and actually what policies
• 8:44
  - and standards they're being held accountable to. And
• 8:46
  - from there, both parties can really focus on
• 8:50
  - improving the processes.
• 8:52
  - And then, again, the payer can really focus
• 8:54
  - on
• 8:56
  - addressing the legacy cleanup
• 8:58
  - retroactively,
• 8:59
  - but also proactively as well.
• 9:02
  - I wanna talk a little bit more about
• 9:04
  - the transparency piece that you just mentioned because,
• 9:06
  - again, I think the finger pointing that you've
• 9:08
  - touched on earlier is very real. Unfortunately, it
• 9:11
  - it still exists. It's going to exist for
• 9:13
  - the next probably couple years, if not ever.
• 9:16
  - Again, from a transparency perspective, though, when we're
• 9:19
  - looking at this, what does an education first
• 9:21
  - approach look like then in practice?
• 9:23
  - And, again, speaking of transparency,
• 9:26
  - how can plans
• 9:28
  - create
• 9:28
  - clear expectations
• 9:30
  - then
• 9:31
  - for providers while still tightening their controls that
• 9:34
  - they need?
• 9:36
  - Well, look. As I tell you, you know,
• 9:37
  - an education first approach,
• 9:39
  - it starts with the assumption
• 9:42
  - that most providers want to do the right
• 9:44
  - thing.
• 9:45
  - But just like a payer or a vendor,
• 9:48
  - they're operating in a highly complex environment.
• 9:51
  - You know? They are building charge masters and
• 9:54
  - rules and and processes
• 9:56
  - for multiple payers, and all payers
• 9:59
  - don't have the same guidelines. So, again, it's
• 10:02
  - important to start with the assumption that they
• 10:05
  - want to do what's right and are currently
• 10:08
  - doing what is right to the best of
• 10:10
  - their ability.
• 10:12
  - You know?
• 10:13
  - It also means that when you're using the
• 10:15
  - data,
• 10:16
  - you're identifying
• 10:17
  - patterns and opportunities
• 10:19
  - before implementing corrective actions.
• 10:22
  - That is really important because you don't want
• 10:25
  - to make a nonissue
• 10:27
  - an issue
• 10:29
  - because then you're kinda just a bit on
• 10:32
  - on a hamster wheel. Right?
• 10:34
  - And so it's really thinking about instead of
• 10:36
  - leading with
• 10:37
  - denials,
• 10:39
  - or recoveries,
• 10:40
  - plans can really begin by sharing insights,
• 10:43
  - having targeted provider education,
• 10:45
  - and really offering them resources,
• 10:48
  - to help them understand
• 10:50
  - the expectations.
• 10:52
  - You know, as a vendor with Saris, we
• 10:54
  - work not only with our payer clients, but
• 10:57
  - we also work with providers
• 10:59
  - to educate them from beginning to end of
• 11:02
  - what our processes are so they can be
• 11:04
  - more comfortable,
• 11:05
  - with that. And I say the last piece
• 11:09
  - of that
• 11:10
  - is
• 11:11
  - to
• 11:12
  - really
• 11:13
  - maintain consistency
• 11:15
  - as much as possible.
• 11:17
  - And and that may sound contradictory to our
• 11:20
  - conversation
• 11:21
  - about the changes in regulatory requirements
• 11:24
  - and the pace,
• 11:25
  - but it is you still have to remain
• 11:28
  - as consistent as you can be. You know,
• 11:30
  - providers become really frustrated
• 11:32
  - when expectations
• 11:34
  - shift,
• 11:35
  - and they're being told one thing by their
• 11:37
  - customer service team, told one thing by network,
• 11:40
  - told another thing by their PI team, and
• 11:42
  - then the vendor is communicating something completely different.
• 11:45
  - Right? So you wanna make sure that you
• 11:47
  - are consistent
• 11:48
  - across all communication
• 11:50
  - platforms,
• 11:51
  - whether that's in verbal communication, meaning, or especially
• 11:54
  - in writing because that is what both payers
• 11:58
  - and providers,
• 11:59
  - rely on. And it helps to build trust
• 12:02
  - as well.
• 12:03
  - Yeah. You talked about this earlier in our
• 12:05
  - conversation, alignment. Right? Alignment
• 12:08
  - between the two between different teams and then
• 12:12
  - communication on top of that is what's going
• 12:14
  - to enable
• 12:15
  - that proactive approach that you've just touched on.
• 12:18
  - When we're thinking about, again, the pivots that
• 12:21
  - we started our conversation with today,
• 12:24
  - for a small or a midsize plan, for
• 12:26
  - example, trying to stay ahead of all of
• 12:28
  - this, which is a hard task, we are
• 12:30
  - aware.
• 12:31
  - What are some of these early signals that
• 12:33
  - you want leaders to watch, and what are
• 12:36
  - those strategic
• 12:37
  - moves
• 12:38
  - that you think that you would advise, okay.
• 12:41
  - This needs to happen today?
• 12:43
  - I I would say we we start with
• 12:45
  - a good foundation. Right? So to me, there
• 12:48
  - are three areas that no matter the size
• 12:50
  - of the plan, you always want to look
• 12:52
  - at. First is federal guidance.
• 12:55
  - Second is state level policy changes,
• 12:58
  - and then also audit trends.
• 13:00
  - So there's there's a plethora
• 13:02
  - of information out there, but sometimes you really
• 13:05
  - do need help in cutting through the noise
• 13:07
  - and identifying
• 13:09
  - what's truly important to your particular plan, what's
• 13:12
  - important to your members,
• 13:14
  - and how you are addressing reducing
• 13:17
  - medical spend. Right? That that's what we're all
• 13:19
  - trying to look at and making sure that
• 13:21
  - claims are reimbursed appropriately. That's that's the entire
• 13:25
  - goal for both sides of the coin.
• 13:28
  - And so, you know, one of the earliest
• 13:30
  - indicators of a future regulatory focus comes from
• 13:33
  - audit findings.
• 13:35
  - I say that OIG provides a lot of
• 13:37
  - information out there,
• 13:39
  - at a very high level. But, again, when
• 13:42
  - they're doing that extrapolation, we know if it's
• 13:44
  - happening on the on a macro level, it's
• 13:46
  - definitely happening on a micro level,
• 13:49
  - as well. So monitoring those changes.
• 13:52
  - And when you're monitoring those changes, especially between
• 13:54
  - federal and state, you wanna identify any differences
• 13:59
  - or any conflicts
• 14:01
  - just between those two first.
• 14:03
  - And then from there, you dive into, based
• 14:06
  - on what we've researched,
• 14:07
  - how does that compare
• 14:09
  - against our own policies?
• 14:12
  - Whether that is claims adjudication,
• 14:15
  - whether that is a reimbursement policy or provider
• 14:17
  - manual. Are we in line with state and
• 14:20
  - federal guidance? Do we need to create more
• 14:22
  - policies or find opportunities to make our policies
• 14:26
  - more robust or as specific as possible?
• 14:29
  - So that, again, is that communication,
• 14:31
  - is that transparency
• 14:33
  - piece of it all comes back around full
• 14:36
  - circle. Right? And I'd also say
• 14:40
  - that consistency
• 14:41
  - piece of it is also making sure that
• 14:45
  - you are enforcing
• 14:46
  - what those policies
• 14:48
  - are.
• 14:50
  - Sometimes we have a tend to overcorrect.
• 14:53
  - Right? But once you've understood the data, you've
• 14:56
  - had those meetings with those cross functional teams,
• 14:59
  - it really gives you a holistic picture
• 15:02
  - of your operational readiness. Right? And as you
• 15:05
  - start that provider communication,
• 15:07
  - you're able to communicate to them to see
• 15:09
  - where they are. Again, we're all running in
• 15:11
  - the same race, and we're trying to keep
• 15:14
  - the same pace. And so, again, we both
• 15:17
  - reach success when we both understand,
• 15:19
  - hey. Here are our challenges. Here's how we
• 15:21
  - can work with you on the interim, and
• 15:23
  - then here is where we wanna get to
• 15:25
  - inevitably after, you know, a a specific amount
• 15:28
  - of time.
• 15:30
  - Theresa's advice, don't point fingers. Just execute.
• 15:34
  - That's the way to go.
• 15:36
  - But
• 15:37
  - Cross cross functionally execute. Right? Exactly. Exactly. Theresa,
• 15:41
  - it's so great to have you. Thanks so
• 15:42
  - much for taking some time for us.
• 15:44
  - Absolutely.
• 15:45
  - Yeah. It's great to have you. We also
• 15:46
  - want to thank our podcast sponsor, Sarris. You
• 15:48
  - can tune in to more podcasts from Becker's
• 15:50
  - Healthcare by visiting our podcast page at beggershospitalreview.com.