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In response to COVID-19, many health care operational guidelines, practices and regulations are “flexing.” 

This helps ensure there’s adequate capacity to identify and treat those suspected or confirmed to have contracted the disease. It also helps people who need care and treatment for conditions not related to COVID-19.

In this rapidly changing situation, it’s critical that health plans enable mechanisms to effectively track and monitor the changes they make throughout their organization. 

Health plans can’t afford the operational challenges that will result from increased pend, denial and call volumes. Nor the damage to reputation that may result if their processes cause nonpayment of claims for services rendered in good faith. 

Health plans are rapidly removing barriers and administrative burdens and increasing access to care. They must also implement tracking and controls to prevent inadvertent errors and the potential fraud and abuse that often occur in times of crisis and chaos. 

Doing so will also allow their operations teams to reestablish the guardrails and guidelines that were in place before the emergency.

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Health plans are feeling the impacts of COVID-19 across the value chain. This includes:

  • Off-cycle enrollment additions
  • Provider contract requirements
  • Value-based care incentives
  • Authorization requirements
  • Claim payment policies
  • Operational inventory management
  • Reporting requirements

No operational function within a health plan is untouched by the rapid changes resulting from the COVID-19 pandemic. 

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Timely filing requirements

Most health plans have a timely filing provision in their provider contracts. A provider must submit claims within a specific time frame following the date of service. 

With the health emergency declaration, individual states have provided specific guidance around timely filing for their state. 

Indiana, for example, doubled the timely filing period from 90 to 180 days through the period of the emergency declaration. Illinois extended its 180-day timely filing period to two months beyond the date of the public health emergency. 

Health plans will want to think through their timely filing requirements. Beyond making the requisite system modifications, they should clearly communicate with providers and equip their provider services teams to answer questions. 

Plans will want to understand and account for impacts in other areas, such as:

  • Encounter data submission and acceptance, particularly for states and other agencies that reject encounters where the claim was not submitted within the required time frame
  • Provider scorecard and incentive program calculations and reports, ensuring they’ve been updated to account for any policy changes
  • Incurred but not reported (IBNR) estimates to account for potential delays in receiving claims

Credentialing requirements

Payers typically have very stringent requirements and processes for credentialing providers. In some cases, they only allow fully credentialed, in-network providers to render care and deny claims from non-network providers.

In many states, providers rendering services to Medicaid managed care patients must be “registered” with the state’s Medicaid system. With the need to ensure a sufficient clinical workforce to address the pandemic, many states have relaxed credentialing requirements. 

They’ve allowed providers to practice in a state in which they are not licensed. Other states are expediting the process for retired providers to reactivate their license if they have retired. 

Health plans want to ensure their systems are configured to pay claims from valid providers. They also want to ensure they maintain the appropriate tracking to follow through with full credentialing. Or they may need to deactivate those providers’ licenses when the crisis eases.

Provider Data

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How do health plans ensure that an increase in claims that need provider data updates doesn’t result in a surge in claim inventories?

  • Have a sufficient level of resources trained to load provider data
  • Streamline the validation and loading processes
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Provider demographic and contractual data is critical to paying claims. The lack of accurate or up-to-date provider data can slow the claims adjudication process until the correct information can be added to the system, in what is often a manual and labor-intensive process. 

There are many areas in which provider data may change in response to the COVID-19 crisis. 

  • Hospitals may have added capacity with alternate care sites. These many include nontraditional sites such as motels or mobile field hospitals.
  • Practitioners may be practicing in states in which they are not licensed and at locations with which they have not been affiliated.
  • Providers may bill for services outside those specified in their contract with the health plan. Depending on the plan’s system configuration, claims for providers that fall into these categories could be denied automatically or pend. This requires intervention to update the plan’s systems before the claim can be adjudicated. 

Provider contracts

Here are a few key considerations for provider contracts.

Provider performance. Plans will want to review and evaluate their value-based contracts and provider incentive programs. What challenges might providers have? What exceptions might they request in reporting timelines, measurement periods and other factors? 

States are mandating that providers cease nonessential medical procedures. Patients are required to shelter in place. Health plans may want to take proactive steps to engage early with providers on these and other areas of concern.

Reporting requirements. To provide flexibility yet maintain appropriate oversight and operational discipline, health plans should consider whether they will:

  • Waive contractually required reporting requirements
  • Extend the timelines for report submission
  • Make other accommodations 

Timeliness of services. Health plan contracts and provider manuals frequently have standards of care for appointment availability and office wait times. These requirements may be part of an incentive program and are part of NCQA-accreditation reviews. 

Health plans need to consider how they will evaluate provider performance in these areas. And they will want to ensure their reports, policies and quality programs take into account any modifications made to the standards.

Many areas within a health plan’s operations have been and will continue to be impacted by the changes in how, where and by whom treatment is rendered and for what services. 

With relaxed guidelines and policy changes, ensuring effective, timely cross-functional communication, collaboration and execution is critical. It’s the only way to ensure operational excellence during the crisis, and maintaining it in the weeks and months to come.

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About the authors

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Craig Savage

Craig Savage leads the payer advisory practice of Optum Advisory Services. In this role, he partners with leading health insurers to drive sustainable growth and profitability amid rapidly evolving business and operating models, advanced technologies and enterprise capabilities. Craig and his team bring strategic insights and implementation expertise informed by deep health care operations knowledge and the unique delivery capabilities of Optum.

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Mallory Van Horn

Mallory Van Horn has 20 years of health care experience, including HEDIS and CAHPS. She currently oversees the Health Management and Operations practice for Optum Advisory Services. Prior to joining Optum Advisory Services, Mallory served as the national HEDIS director of UnitedHealthcare Community and State. In that role, she had accountability for over 80 HEDIS and CAHPS submissions on an annual basis.

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Colleen Zickgraf

Colleen Zickgraf is a senior director with Optum Advisory Services Payer Consulting Practice, working with payers across the U.S. to solve their most critical operational challenges.

She has more than 25 years of experience working with health plans to transform their operations improving productivity, quality and efficiency, while driving down costs.  

Colleen has led teams on engagements to improve business operations and define consumer experience strategy, and has twice filled a role as interim chief operating officer for clients.

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Donna Holmes

Donna Holmes is a vice president within Optum Advisory Services leading business development and delivery teams for the Payer commercial business.  

She brings more than thirty years of experience providing a balance of extensive business management and technical experience and leadership skills to diagnose issues quickly and to execute appropriate plans necessary to ensure excellent service, growth and profitability.  

Donna has worked with Fortune 100 clients in both strategy and delivery roles on projects involving implementation and improvement of business processes and cross functional capabilities to improve consumer experiences and operational efficiencies. 

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