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