Latest / Becker’s Payer Issues Podcast / Moving Payment Integrity Upstream with Jhana Spence of CERIS

Transcript

Moving Payment Integrity Upstream with Jhana Spence of CERIS · Becker’s Payer Issues Podcast

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  Hi, everyone. This is Lucas Voss with Becker's
• 0:02
  Healthcare. Thanks so much for tuning in to
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  the Becker's Healthcare podcast series. It's great to
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  have you. Today, we're talking about the evolution
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  of payment integrity, and I'm very excited to
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  welcome Jana Spence. She's the vice president of
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  strategy at Saris with close to two decades
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  of experience in client relationship management, partner revenue
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  growth, and client advocacy. Jana serves as a
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  trusted adviser to her customers and continues to
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  advance payment integrity strategies for health care organizations
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  nationwide.
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  John, it's so great to have you again.
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  Welcome to the podcast.
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  Well, thank you for having me back. Absolutely.
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  I wanna jump right in. There's quite a
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  bit to talk about today here. You and
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  your colleagues at Syrris frequently speak about prioritizing
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  a moving
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  left
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  strategy and payment integrity.
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  Can you just define that approach for our
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  listeners here, and why has it become so
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  important
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  for health plans right now?
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  Yeah. Sure. So when when we talk about
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  moving left or you might even hear people
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  say upstream
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  Mhmm. At a high level,
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  we're really talking about an easy way to
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  say shifting PI activities
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  to earlier in the claim life cycle.
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  So they should be happening
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  closer and closer to the moment of a
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  claim being submitted or even adjudicated,
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  or some are even talking about at the
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  point of authorization.
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  So this versus
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  relying almost entirely on solely post payment audits.
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  So, historically, you know, payment integrity has been
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  very reactive.
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  We pay the claim first, and then we
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  go back later and say
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  or ask ourselves, you know, was that correct?
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  Moving left flips that question to
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  how do we make sure it's correct before
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  payment even goes out the door?
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  Now what's important is that we're applying intelligence
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  earlier
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  through the use of better data,
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  better analytics,
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  better workflows.
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  And so this means accuracy is built in
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  rather than bolted on afterward.
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  And this has become especially important right now
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  for a few key reasons.
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  You know, I'll set the stage a little
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  bit, and then narrow it down to, I'd
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  say, really kinda maybe three reasons why it's
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  important.
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  So the first I would say is financial
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  pressure.
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  The environment for health plans is, you know,
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  that they are operating,
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  in a space with rising medical costs,
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  increased utilization,
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  and then increased regulatory
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  complexity just to top it all off. So
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  the margin for error is incredibly thin.
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  Look. Plans can't afford to let millions of
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  dollars leak out the door and hope to
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  recover a percentage of that later.
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  Second, I would say this is an important
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  strategy
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  to manage changing provider dynamics.
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  Providers are under the their own pressure,
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  and tolerance for retrospective audits is just lower
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  than it's ever been.
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  Post pay recoveries, you know, they create an
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  administrative burden,
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  appeals,
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  and just frustration,
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  which ultimately
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  strains that relationship between,
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  plans and providers and and one that's very
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  important to our plans.
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  And then I'd say last,
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  my third important
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  call out is, you know, there's a maturity
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  factor. Right? Technology
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  and data availability,
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  have evolved to the point where moving left
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  is not only possible,
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  it's expected.
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  You know, plans that are not modernizing
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  are going to fall behind those that do.
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  Now you've highlighted the fact that this needs
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  to be a proactive approach. Right? We need
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  to move on from sort of the the
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  post pay audit era, the post pay audit
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  processes. Right.
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  When we're looking at this traditional model in
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  and of itself today,
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  and you've touched on this a little bit,
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  for you, what are the greatest limitations,
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  right, when we're looking at it both from
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  a financial perspective and a provider relationship perspective?
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  Well, I think it's worth saying post pay
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  audits have absolutely delivered value over the years,
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  and they still have a purpose in PI.
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  But as you said,
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  it also has very real limitations.
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  So, traditionally, the post pay model, again, kinda
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  looks like, you know, claims are paid quickly
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  so that they can meet the turnaround requirements,
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  and then a subset of those claims are
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  then selected weeks or months later for an
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  audit.
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  We identify errors,
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  and then recovery efforts begin through offsets, refunds,
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  or appeals, you know, that can take up
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  to two years.
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  The first limitation
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  of that is financial. Right? So not not
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  every identified overpayment is recoverable.
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  Providers may dispute the finding.
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  The statute of limitations may apply.
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  And so those types of things, you know,
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  kinda increase the cost to recover,
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  and so then
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  your recovery actually becomes less than
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  what you maybe even originally expected.
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  The second challenge,
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  I would say is relational.
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  You know, so from the provider's perspective,
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  post pay audits can feel punitive and abrasive,
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  even when they're justified.
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  And so you you might even hear providers
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  say, you know, if this was wrong, then
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  why'd you pay it in the first place?
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  And that kind of question erodes that trust
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  that we have between plans and providers
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  and increases friction.
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  You know, what we're seeing today is that
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  post pay works best as a backstop,
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  not as the foundation of a payment integrity
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  strategy.
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  So it should catch what slips through, not
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  be the primary way plans manage,
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  you know, their their revenue cycle or, you
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  know, the revenue cycle management.
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  Mhmm.
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  Now
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  when there where there's post, there's also pre.
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  And if what we what we've highlighted is
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  the fact that we are trying to be
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  more proactive. That's the approach here. Right?
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  When we talk about shifting to that prepay
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  model and process,
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  what does that look like in practice?
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  And then also, you've touched on the data
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  piece and the analytics part of this. Right?
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  How are then health plans also leveraging technology
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  to really improve all of this
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  before
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  we have budget and monies go out the
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  door?
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  Yeah. No. Good question. So simply put, prepay
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  means applying that technology and that intelligence before
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  payment is released.
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  And then that intelligence,
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  you know, or technology
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  can take many forms.
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  You know, payment integrity,
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  and specifically,
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  Cirrus, you know, we focus on, you know,
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  clinical and coding validation,
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  policy and contract alignment, or even compliance of
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  the contract,
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  and predictive
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  risk scoring of claims that are likely to
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  be paid wrong.
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  Now what's changed in the last five years
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  is that that technology now allows this to
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  happen in near real time. So health plans
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  are leveraging advanced analytics,
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  things like machine learning,
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  to identify claims that are high risk but
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  low volume.
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  These are the claims where even small mistakes
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  can mean a lot of money going out
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  the door inappropriately.
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  So instead of reviewing everything, plans can focus
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  on the claims that really matter.
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  And the key point really is targeting. We
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  don't wanna stop every claim.
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  Ideally, we're only stopping the ones that we
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  truly suspect have errors and let low risk
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  claims flow straight through and kinda follow more
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  of that, post pay model.
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  Another key is to apply automation
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  anywhere possible
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  and really only relying on human expertise where
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  it adds real value,
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  like the validation stage, right, our nurses and
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  our auditors.
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  And then this allows us to improve accuracy
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  and preserve
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  the speed
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  of getting that claim paid, two things that
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  historically
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  have been a a real challenge to balance.
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  From your experience and the conversations that you're
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  having
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  with organizations
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  right now, is there a particular workflow
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  that you're seeing where you think, hey. There's
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  there's more opportunities. There's there's the greatest opportunity
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  potentially
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  for leaders to really say, okay. We have
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  this technology. We need to leverage it more
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  efficiently. What's that workflow for you that really
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  sticks out?
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  Easy. The biggest opportunity we see is in
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  those complex high dollar claims. Right? That's that's
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  the workflow.
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  And, honestly, that doesn't change from from post
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  pay to prepay,
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  you know, when we're talking about a chart
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  audit.
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  Inpatient admission
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  admissions and outpatient surgeries, those types of bills,
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  you know, where,
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  documentation,
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  nuances,
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  and some, we'll say, coding decisions can overlap.
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  And these are claims
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  often correct, but when they're not,
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  the financial impact is is fairly large.
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  So
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  technology,
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  I'll say, can help plans identify some of
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  these mismatches
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  between diagnoses
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  and the level of care and coding that's
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  actually being used,
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  and then also services that don't align with
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  clinical and reimbursement policy.
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  Now,
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  then I'd say with the technology, you know,
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  plans can intervene early and collaboratively, right, rather
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  than months later,
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  the recovery later. And that's really the goal.
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  Yeah. It enables the proactive approach. Right? It's
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  it's going to make things a lot easier,
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  as we've talked about on the front end
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  to be able to eliminate some of this
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  friction.
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  As we were looking to the future, we
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  know that, again, technology isn't going away, right,
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  especially when we talk about some of the
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  automation pieces to this. It's going to evolve,
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  over the next couple of years tremendously fast
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  most likely.
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  How do you see payment integrity evolving here?
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  And, again, what will ultimately differentiate
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  leading health plans from the rest in all
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  of this?
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  Well, call me an optimist.
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  But to me, the future of payment integrity
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  is
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  proactive
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  and collaborative,
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  and then more maybe even more importantly,
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  integrated in the platforms.
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  First key element's gonna be early adoption.
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  Right? So I'd say recently maybe I'll share
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  a story. So recently, I listened to a
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  podcast
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  on AI adoption,
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  completely unrelated to health care. Mhmm. And the
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  message was simple.
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  Get on board early or you'll fall so
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  far behind that catching up becomes
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  impossible
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  or at a minimum incredibly difficult.
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  Payment integrity is no different.
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  Applying PI further upstream
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  isn't a future concept.
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  It's already happening,
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  and it's going to continue to move earlier
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  in the process.
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  So we're seeing it push into as early
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  as clearinghouses
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  today,
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  into authorization workflows.
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  And some even argue, ultimately, it'll be at
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  the point of care of the patient
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  that they're already flagging errors.
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  And health plans that aren't laying that foundation
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  now through, again, data strategy,
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  technology, and process design, they will be far
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  behind those that are putting those things in
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  place, and those planes will be better positioned
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  to take that next step.
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  So for them, moving further left becomes an
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  evolution,
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  you know, those that are executing on this.
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  And then for those that wait, it becomes
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  a much heavier lift.
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  Yeah.
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  You have to start now. You have to
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  be pro as we've talked about, you have
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  to be proactive now to be able to
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  look ahead, and that goes for for technology,
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  but overall the organizational mentality too when it
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  comes to some of these processes that we've
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  discussed. John, it's so great to have you.
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  Anything else that comes to mind that that
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  is important for our listeners that might be
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  important to touch on that we we haven't
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  talked about?
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  No. I would say this has been a
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  great conversation. I think I say it every
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  time, you know, I meet with you,
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  but, you know, Sirius is here to collaborate.
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  We love it.
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  I personally have a a passion for getting,
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  you know, great minds together. So if anyone
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  ever wants to brainstorm,
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  don't hesitate to reach out, to myself or
• 12:22
  to anyone here at Sirius.
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  We talked about partnerships and relationships, so crucial
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  in this space.
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  Yes.
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  Jonna, it's so great to have you again,
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  and we also want to thank our podcast
• 12:33
  sponsor, Sirius. You can tune in to more
• 12:34
  podcasts from Becker's Healthcare by visiting our podcast
• 12:37
  page at beckershospitalreview.com.