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