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Three strategic guideposts for health plans in the fast-paced digital age: Part 3 – Payment Integrity Solutions

Welcome to the final chapter of our three-part series, where we navigate the evolving landscape of the digital age for healthcare payers. In part one, we unveiled the fundamental role data democratization plays in improving insights, member experience, outcomes and compliance.  Part two dissected the technological marvels and data-driven solutions propelling health equity. Now, in part three, we set our sights on the guidepost that illuminates the path forward to business sustainability: payment integrity. 

Dollars and data: The cybernetic landscape of payment integrity 

Today, the payment integrity space is estimated to be a $9 billion industry[1], ever growing in complexity and challenges that include:

  • The shift to value-based care payment models tying analytics to adjusted reimbursement, approaching 60% of all reimbursement
  • Regulatory changes, contracting nuances and coding updates

Given the magnitude of the situation, many payers don’t have the internal resources or experience to recover all they’re entitled. Internal processes often lack the expertise and technology necessary to identify and shore up payment leaks. Engaging an experienced PI vendor with focused expertise provides payers a robust and dedicated team to increase identification and recoveries.

Benefits ballet: A tale of synchronized Coordination of Benefits (COB)

For COB, adjudication relies on accurate reflection and order of primary, secondary, tertiary coverage and beyond. This is not an easy task, as many members’ coverage is fluid.  On top of that, there’s a subset of members who do not even realize other coverage exists, especially when numerous dependents exist on a single policy.

But what if payments could be fixed before the erroneous payment occurs, reducing the traditional “pay and chase,” model? Developing recovery processes that leverage data to recoup overpayments and prevent further errors is the future for payment integrity, including COB.

Conduent has developed such a recovery process with our Payment Integrity Solutions.  In fact, we believe that savings – garnered by proactively addressing the root cause of the incorrect payment – should be passed on to the member.

Our goal is to bend the healthcare cost curve one payer, one member at a time.

Real results:

Many of our clients see considerable savings in the first two years. Here are just a couple of examples:

Lost in the minutiae

For one health plan, moving its new line of business to Conduent resulted in the immediate identification of a member with $1M in claims that had previously been paid incorrectly. 

Result: The plan was able to update the member’s record and recover the full $1M. 

Discovered by an algorithmic sleuth

For this Medicaid managed care organization (MCO), members shared in the monthly costs or deductibles before the plan paid benefits.  Nuances in the data unveiled a myriad of discrepancies, such as: incorrect provider billing, lack of patient funds at time of service and in some cases fraud, waste and abuse.  

Result: Using a proprietary algorithm, over $3M was recovered in overpaid claims in the first year. Providers began billing correctly up front as they knew the claims were being audited and the amount identified as overpaid dwindled. Additionally, an update to their claim payment system allowed for prospective identification of overpayments. 

The power of synergy:

Financial stewardship in healthcare embodies a commitment to responsible and ethical management of revenue and resources, with a focus on ensuring the sustainability and well-being of the healthcare ecosystem. Payment integrity is the essence of financial stewardship.

As we conclude this exploration, it's evident that the pursuit of fast-paced digital health transcends singular elements; it's a collaboration between data, technology, process and people, each playing a crucial role in achieving the highest levels of accuracy, efficiency, compliance and value in healthcare.

About Conduent Payment Integrity Solutions

Our payment accuracy solutions seamlessly integrate with multiple data sources, analytics, technologies and nationwide footprint to help you recover the most funds possible. With over 30 combined years in the industry, our tenured staff has identified hundreds of millions in recoveries for our clients.  We work with 17 of the top 20 US health plans.  And, when you bundle one or more of our 4 solutions – COB, Credit Balance, Pharmacy Audit and Subrogation – you save even more.

About the Author

Kimberly Coffey is senior managing attorney and director of recovery operations for Conduent’s payment integrity subrogation solutions. She’s responsible for developing the solution, creating its roadmap and liaising with sales teams to nurture client relationships and expand the portfolio. Prior to joining Conduent, Kim worked in private practice for 10 years, primarily in worker’s compensation and personal injury litigation. Kim holds a bachelor’s (BA) degree in economics from Eastern Illinois University and a law degree (JD) from Northern Illinois University.

Profile Photo of Kim Coffey