Hi, everyone. This is Lucas Voss with the
Becker's Healthcare podcast series. Thanks so much for
tuning in today. Very excited to have you.
And I am excited and thrilled to be
joined by Mark Johnson, senior vice president at
Saris, who will talk to us about payment
integrity. Very important topic. Mark, thanks so much
for being here today. Thanks for having me,
Lucas. Appreciate it. Mark, we'll start off with
introductions here. If you just wanna give us
a quick introduction to yourself and just your
your background in health care and your career
so far.
Absolutely. I've been with,
Cirrus now for a little over five years,
but my background, you know, is around thirty
years experience in the health care space. I've
been in patient care at the bedside,
into medical billing, payment integrity, insurance.
Really, I've I've led significant product improvements in
that thirty years at Cirrus. We're part of
the CorVel Corporation.
I've been at Blue Cross Blue Shield in
Minnesota.
I had a stint at UnitedHealth Group as
well. My background includes patient care,
payment integrity,
vendor management,
regulatory
compliance.
I've done some international
operations startups as well.
Educationally, I've got a bachelor's degree in physiology
from the University of Minnesota
and an MBA from Regis University.
Go Gophers
in in that case. Go Gophers. Go big
10. Yeah. Ex exactly. We'll we'll go with
that.
Well, again, Mark, it's it's great to have
you, and this is an important topic today.
I was doing research for this podcast, and
and this stat just really stood out to
me. There's an estimation that up to eighty
percent yes. You heard that right. Eighty percent
of medical bills
contain
errors, which is staggering.
As leaders in the payer space increasingly
look to really optimize
processes, we know that's happening, especially around billing
and payments.
What's the role of payment integrity
from your perspective, and why is it so
important?
Yeah. Payment integrity
in the payer space is incredibly important. It
just ensures that claims are accurately
processed
and more importantly, accurately reimbursed
to the providers.
It helps prevent errors, fraud, waste, and abuse.
Really, this is crucial
because it helps maintain financial stability, not only
for the payer, but for the providers being
impacted.
It also enhances the trust between the payers
and the providers.
And, you know, lastly, it ensures that the
health care dollars are being used appropriately.
That's why payment integrity is so important.
Yeah. It's sort of a I view it
sort of as a as a foundational
piece. It's really the foundation that a lot
of things stand on. And if that foundation
isn't there,
then there are going to be problems as
you've outlined.
And
the process is is really key to this
to this area,
the process around,
around everything that you've touched on.
How can changing the process
around payments
reduce some of these numbers of errors, right,
80?
And what strategies have you found beneficial?
Do you have any examples that that stood
out to you and some of the results
that that you see that that make a
difference?
Sure, Lucas. I'm I'm trying to think over
thirty years, payment integrity really didn't exist thirty
years ago. Right? And it's going through a
lot
of transition right now, a lot of growth.
I can think of maybe four or five
key strategies that payers might wanna contemplate.
The first would be
to centralize their payment integrity strategy.
Take a centralized approach that integrates your prepay
editing reviews,
your post pay auditing capabilities,
and as well as your innovation teams, your
r and d teams in order to streamline
processes
and try to reduce those errors,
especially prepayment.
Secondly, I would say
when you're thinking about artificial intelligence
and machine learning, those are big buzzwords
lately,
really think about it as a complement to
the clinical teams that you have deployed in
your payment integrity space as well as your
certified coders.
Utilizing AI,
machine learning for real time analysis of claims,
proactively
identifying high risk claims,
and really helping your clinicians and your coders
identify,
those claims quickly can significantly
enhance your accuracy and as well as throughput
for the teams working those claims.
Third strategy,
contemplate a second pass claims editing process.
A second pass vendor, second pass process, or
even a final filter on claims
can really help catch errors that are missed
in primary editing phases.
Just, again, reducing inappropriate payments from going out
the door.
Fourth, and this is a big one,
coordination of benefits.
Mhmm. We really need a strong coordination of
benefits program. You may want to consider adopting
a pause and pay approach
with advanced analytics again, right, to ensure you're
correct payment responsibility,
eligibility validation before the claims are even paid.
Just reduce that overpayment from going out the
door
and all of the overhead associated with the
pay and chase model.
Lastly,
quality assurance programs.
Establishing a robust
QA program
to conduct pre billing audits can really catch
errors early and then just improve overall billing
accuracy.
I guess with these strategies,
you know, health care payers
can really enhance their payment integrity program and
reduce those errors, really ultimately
improving overall financial performance.
Yeah. Absolutely. And just as a as a
quick follow-up to that, should this be a
a holistic approach as in we're focusing on
all of these strategies, we're incorporating them all,
or is there one focus area from the
things that you just mentioned that that, organizations
should look at?
I all. I would I would be looking
at all of these right now. If you
had to prioritize,
something, I would I would try to centralize
your payment integrity strategy.
You may have payers may have post pay
services, prepay services,
clinical utilization
management services, all under different
leaderships
Mhmm. Or strategies.
And some of those strategies may be at
odds with each other. Make sure you're all
aligned
first.
And then you then you can really start
digging into
solutions,
vendor partners,
like Cirrus
or any other,
technology play.
Yeah. Absolutely.
Which leads me to my next point, and
this was one of your your strategies or
one of the pieces of that you've mentioned
that are really important right now. The modernization
efforts
efforts that are happening in the payer space.
They are all over. You've mentioned the buzzwords.
Right? AI. It's it's all over the place.
Again, touch on how you see technology
evolving and really making an impact on reducing
errors and enhancing
payment integrity.
What are you looking forward to right beyond
those buzzwords, and how should organizations prepare?
Wow. That's it's such a big area. The
technologies are just evolving
so rapidly.
I would say that if if you have
an AI strategy,
excellent. If you don't, get one quickly.
Innovations such as artificial intelligence,
digital payment systems,
finance solutions, just embedded finance solutions are really
transforming health care payments. Mhmm. Providers
themselves
are starting to look at these these technologies
as well to help them with their revenue
cycle.
So while this these technologies
I mean, all of this tech play
can really help automate billing processes and reduce
manual errors and just improve that rev cycle
for both payers and and providers.
It's still going to be important to have
that
human
touch, that clinical
overview, that coder overview.
You don't want to get caught
automating your your edits, automating your your solutions.
Technology can help,
but you shouldn't put all of your eggs
in just in that baskets.
You know, adopting advanced payment technologies,
making sure that that cash is flowing
smoothly and accurately between the payer and the
provider. And I think that's that's really where
you're gonna wanna be focused.
Yeah. Absolutely.
Well, Mark, thank you so much for sharing
all of your insights here. Again, thirty years
of experience. We really appreciate you taking the
time today. Thanks for being here.
I appreciate it, Lucas. Thank you for the
time. I I really do.
Yeah. Absolutely. Thanks for sharing everything. And I'd
also like to thank Suresh as well for
sponsoring this episode. And you can tune in
to more podcast from Becker's Healthcare by visiting
our podcast page at beckershospitalreview.com.