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Why a comprehensive payment integrity strategy is key

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Host: Welcome to Optum's Ask the Experts series focused on uncovering hidden funds with comprehensive payment integrity. In our first podcast, Robert Mayer, Vice President of Product Strategy for Optum's Payment Integrity Solutions discusses why health plans should consider a comprehensive payment integrity strategy.

What elements should payers consider when exploring a comprehensive payment integrity strategy?

Robert Mayer: The main element's understanding your current medical expense savings from all of your existing payment integrity assets and then setting goals to improve upon it moving forward. Additionally, any organization should consider how they are structured today and that they believe they have the key person or role, they can begin to look at payment integrity as an enterprise asset even if the functions cross over multiple departments today. Finally, a health plan should assess if they feel they have the knowledge in-house, understand what a mature payment integrity program looks like to help create the roadmap to improve the strategic function.

Host: Where are health plans on the payment integrity maturity model?

Robert Mayer: Optum utilizes a five-stage maturity model for payment integrity with stage one being typical and stage five being optimized. In stage one, we see health plans with a very fragmented approach to managing payment integrity. These health plans have made departments, vendors and roles each working separately in a silo, and perhaps duplicating themselves and without effective communication. Additionally, we typically see a stage one health plan mostly focused on post-pay items. As a result, health plans in this stage are typically saving the lower ends of medical expense, around 1 to 3%.

As the model matures, we begin to see less fragmentation amongst departments and vendors and more of a focus around dashboard reporting, centralizing control of the payment integrity assets and vendors and an increase in medical expense savings. At the high end of the model are most mature state, you have the optimized health plan. This health plan is a central payment integrity office with an executive leader reporting into the C-Suite and is responsible for all payment integrity-related activities from end to end. They're saving the higher ends of medical expense, around 8 to 10% annually, they have clear goals reporting and a strategy laid out to have a continually moved savings from post-pay to pre-pay.

Host: What are the first steps payers should take on their comprehensive payment integrity journey?

Robert Mayer: First of all, we need to listen to each client and to understand their unique needs, their organization to come up with the best plan tailored to them. Not every health plan is ready to be at the highest end of the maturity model on day one. It will take time. Understanding a client's goals and what they are trying to achieve helps us establish a plan of how we could help them get to where they want. Outside of increased savings potential, which every health plan is interested in, there is a change management aspect with increasing your payment integrity functions that might take time to develop, both internally within the organization, but also externally with their employer groups and providers in establishing new practices and routines.

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A comprehensive payment integrity strategy can unlock hidden funds. Listen as Robert Mayer, vice president of Product Strategy for Optum Payment Integrity solutions, explains why a holistic strategy is vital and what to consider before beginning the journey.