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Essentials to managing prospective payment systems

Insights from Heather Johnson, Manager, Process Management, Payment Integrity, Optum

Prospective payment methodologies carry opportunity and risk for payers and providers alike. It takes resources and expertise to ensure the accuracy of provider reimbursements — particularly in the face of constant regulatory and pricing changes for commercial, Medicare and Medicaid.

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An effective prospective payment system provides the foundation and sustaining architecture that enable cost-containment strategies to achieve a balance between profitability and risk sharing.

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What are prospective payment systems best practices?

It’s important to have a team that understands the pricing changes and other continual updates, and can deploy them accurately and on schedule. Payers are often surprised at the level of updates and the sheer number of moving parts that need to be addressed.

In addition, each line of business has a different schedule for system releases. Those need to be carefully planned and well communicated with all the stakeholders — from IT, to the business, to the provider.

Testing and validation are also essential to avoid provider abrasion and achieve the desired outcomes. If you have updates that are not deployed correctly or fully validated, you may experience a substantial issue months later. Beyond causing provider dissatisfaction, you also risk fees and penalties if the pricing is incorrect.

Another way to minimize issues with providers is to set up a help desk for questions. Understandably, this may be a resource drain for a mid-size or smaller payer, but it is important to deal with issues as quickly as possible, before they damage a provider relationship.

It’s important to make sure all aspects of the methodology are working in sync to achieve the greatest reward and avoid significant risk.

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How many staff people do health plans typically dedicate to prospective payment activities?

One or two is normal; larger payers may have four or more. The key is to have enough experts able to keep up with the regulatory content and other changes, and provide excellent documentation that is defensible. What is your strategy when there is turnover? How will you know why certain decisions were made or processes implemented if questioned during an audit? Payers that are understaffed can find themselves at risk during transitions or if the workload becomes too overwhelming.

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What’s the benefit of working with an outside vendor?

It can be challenging for a payer to recruit and keep the talent needed to research, interpret and deploy the ongoing regulatory updates in content and architecture. Making these continual, complex updates requires the right technology skill set in addition to a deep understanding of your business and IT functions. Working with an outside vendor enables you to extend your staff expertise by adding a team that understands your processes and business rationale — and is responsible for ensuring consistency, accuracy and timely deployment.

Each payer is different in its strengths and weaknesses when it comes to prospective payments. Some are strong in deployment but not testing. Others are strong with validation but can’t keep pace with the scheduled deployments. At Optum, our goal is to partner with our clients, allowing them to utilize their resources efficiently. We also provide excellent support and guidance while optimizing the value of their prospective payment systems strategy.

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What level of support can Optum provide?

We can help you resolve resource and timeliness issues that often derail prospective payment systems. You benefit from:

  • Direct access to a dedicated team of expert resources to consistently maintain prospective payment systems applications 
  • Minimized risk of staff turnover due to single-threaded process 
  • Enhanced support options and hours of availability to reduce impact during updates
  • The ability to utilize a single team to support multiple activities, such as migrations, prospective payment systems enhancements, and new business process implementation
  • Bi-weekly or weekly meetings as needed to discuss process, issues and planning
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Insights from Heather Johnson, Manager, Process Management, Payment Integrity, Optum

Heather Johnson began her IT career at LEGO Systems in 1993 supporting various international business-critical software platforms. She then worked as an IT system engineer for a global RD&E firm within the glass industry for seven years managing their patents and intellectual property. She has been at Optum for six years, beginning in the implementation team as a system analyst. She held roles as technical consultant, implementation project manager and solution architect before branching off to begin the Process Management team.