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Hi, everyone. This is Lucas Voss with Becker's

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Healthcare. Thanks so much for tuning in to

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the Becker's Healthcare podcast series. It's exciting to

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have you. And we're talking about an exciting

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topic that's seen a lot of movement lately,

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payer compliance

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and regulatory oversight in health care. And I'm

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so excited to be joined by Sarisa Horner,

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director of policy and payment integrity at Saris.

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Sarisa, thanks so much for being here today

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and taking the time. Thank you for having

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me.

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It's great to have you. And I wanna

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start off with introductions for our audience. Could

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you introduce yourself and just share a little

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bit about your work in health care? Thank

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you so much. So my name is Theresa

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Warner. I'm the director of policy and payment

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integrity here at Saris. I've been with Saris

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a little bit over eight years, but actually

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in the health care industry around eighteen years.

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I started out in health care revenue cycle,

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working for hospitals and really gaining a deep

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understanding

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of what that revenue cycle process is from

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beginning to end and then transition over to

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the payment integrity side,

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working with vendors like Sarris who perform work

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on behalf of payers.

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With Sarris, I actually oversee a few departments,

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between provider relations,

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recovery,

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our internal QA,

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and also policy review and implementation.

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And, Sarrisa, I feel like we need that

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deep understanding today because there's a lot of

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movement as I've mentioned. There's a lot of

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things are happening,

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within the payer oversight space. Right? There's CMS

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ramping up Medicare Advantage audits to to states

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issuing fines related to reimbursement

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practices and and mental health parity. There's so

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much happening right now. And I'm I'm just

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curious from your perspective,

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what are some of those most pressing challenges

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that you're seeing that health plans face and

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and adapting to that new scrutiny to all

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of that movement both on the federal and

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state levels?

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I'd say consistency.

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Yeah.

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You know? And I'd say that that's all

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the way around,

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whether that's from state and federal guidance and

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implementation

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to their own

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internal policies.

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It's very hard

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to be consistent across different states,

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when it comes to specific guidelines, especially when

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you think about,

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something like mental health purity. Right?

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I'm not sure quite how many people are

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familiar with it, but mental health purity basically

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means that

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insurance plans have to treat

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mental health and substance

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use disorders

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the same way that they would treat

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any other condition

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that a a patient may have.

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Yeah.

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You know? And it's it's it's very hard.

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You know, we would think that it's 2025,

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so all benefits would be treat be treated

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equal.

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But, unfortunately, that's not true. So different states

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have different guidelines when it comes to that.

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And they're basically trying to make sure that

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the co pays

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and the deductibles,

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the number of of visits that are available

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for services,

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are the same. Right?

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Even down to pre authorization,

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making sure that if an authorization is not

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required

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for a same or similar,

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physician health benefit or physician health service, that

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that mental health benefit

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is treated in the same way.

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And you've mentioned,

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again, consistency and how hard it is to

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maintain consistency, and it's it's crucial for success,

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obviously. Now consistency becomes even even harder when

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things get more complex, right, as we've talked

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about, and and when things become very dynamic

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because you have to change constantly. And again,

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that obviously impacts consistency there. What are some

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of the strategies that you're seeing payers adopting

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right now to to keep up? Right? And

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I was wondering if you'd also have any

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any sort of example of of tools or

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or examples of of your your work that

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stand out to you.

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Yeah. I would say that,

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consistency is is is pretty

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challenging because

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most payers,

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even most health systems,

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and even vendors,

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you have multiple systems that don't always talk

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to each other. You know? And they are

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not always compatible

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with each other. And so

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it's really trying to be able to be

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proactive

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because that's what, you know, we're looking to

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do when you are,

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implementing different federal and state guidelines.

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And there is a couple of different ways

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to do that, but it does require everybody

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working together,

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and having a central vision,

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and being

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very clear

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about what that end goal,

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and the outcome is that we want to

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have. So I would say first,

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is that everyone kind of talks about AI.

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And I think AI is very important,

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when it comes to looking at at payment

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integrity

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and how data is viewed

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and how data is collected

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across different,

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patient health groups. And so when you look

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at something like risk adjustment,

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CMS has really ramped up their audits on

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that. And so how do payers actually

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tackle that issue

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because

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negative impacts from those risk adjustment audits can

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have very significant financial impact on a payer.

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And sometimes it can be due,

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to the smallest piece of,

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documentation

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either being missing or documented incorrectly.

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And so one of the things that a

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lot of payers do is that they work

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with their internal teams. I like to call

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them cross functional,

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where we're really making sure that

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different departments, whether that's claims or finance,

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are really inputting the information

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that's needed to get down to that granular

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level,

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that CMS will be looking for.

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Yeah. And you've touched on a couple of

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important things here. One, obviously, is being able

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to eliminate silos and having conversations. I I

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again, I love the cross functional piece, right,

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that's so important for success today and being

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proactive

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and, again, AI, such a big piece of

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the conversation as well.

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What are some of those additional capabilities

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or approaches that that you're looking towards for

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the future here for for, obviously, the 2025,

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but 2026

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as well that are really critical for payers

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to look at as they're continuing to to

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navigate the space? And and what's one thing

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that that you think everybody should be doing

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right now to be able to be prepared?

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I think that everyone should be looking beyond

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just traditional fraud, waste, and abuse.

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We all have

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very comprehensive

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systems

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for the most part that are able to

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track that. Now ideally, we would like for

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all of that to be done prepay,

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and that's where the industry is trying to

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move toward is having a lot of these

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audits that are conducted post pay

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transition

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to prepay reviews. It's a lot cleaner and

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it's a lot easier for both parties,

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meaning the payer and also the provider.

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But we really have to look

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at our AI discussion and our, software discussion

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as being able to identify some predictive compliance

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modeling. Right?

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There are ways to use NLP

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and machine learning

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to make the review of records and policies

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much more consistent in being able to identify,

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I say, anomalies in the data or areas

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to focus on beyond just our traditional FWA.

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Yeah. As you pointed out earlier in the

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conversation, this is something that never stands still.

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There's it's always evolving. There's always something new

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happening. So it's really becomes critical to, as

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you've mentioned, be proactive and and looking at

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the tools that can make this better in

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the long run. Sarisa, again, thank you so

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much for your time and insights today. I

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I wanted to open the floor up to

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you here as we close out our conversation.

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Any fun final thoughts or anything that we

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didn't cover that you'd like to share with

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the audience?

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I would say, you know, look. It's just

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in general.

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Compliance is no longer really about just checking

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the box. You know? For decades, we have

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kinda just checked the box of just the

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standard things that we're looking for, whether that's

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timely filing, no authorization,

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met NEC. And as we are seeing with

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the changes in federal guidance and even down

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to state guidance, we are seeing that reimbursement

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when it comes to health care claims is

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a bit more fragile than what we have

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seen in the past. So it not only

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requires

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providers to be more agile,

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but also payers to be very agile.

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And one of the ways that I know

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that payers do is that they partner with

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vendors like Cirrus, where we're able to give

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them that industry knowledge, and we can actually

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discuss what does data transparency

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actually look like. How do you become standard,

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in the information that you're sending, and then

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how do you tighten up those internal processes,

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and make your reimbursement policies most effective and

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most in line with what your goals are.

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Yeah. Well, Theresa, again, thank you so much

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for being here today. It's fantastic to have

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you. Thanks for your insights and your time.

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Thank you very much as well. And I

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feel like we'll have to revisit this at

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some point with everything that's happening. And we

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also want to thank our podcast sponsor, Cirrus.

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You can tune in to more podcasts from

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Becker's health care health care by visiting our

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podcast page at beccarshospitalreview.com.