Evolve to an avoidance-based payment integrity strategy

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Host: Welcome to Optum's Ask the Expert series, focused on maximizing post payment recovery and preparing for prepayment success. In this podcast, Erin Schmuker, Vice President Product Solutions, Payment Integrity Optum, discusses key steps to take when evolving to a prepayment strategy. What is the impact to key stakeholders as we look to move to a prepay strategy?

Erin Schmuker: Stakeholders have to be bought in and ready to work. At this point, we'd all agree that taking a proactive prepay approach to payment integrity is the right course of action, but actually doing it can be a real challenge. Reform, regulations and pricing power declines from exchanges, those are just some of the reasons that health plans have a difficult time remaining focused on payment integrity.

Each organization needs a champion that will help shift that focus from market pressures and from the industry standard pay and chase environment, where we've been living in today, to get proactive about implementing prepayment solutions. Health plans need to be using technology that helps them achieve the most timely and accurate payments, and to help them address the financial leakage that stems from inaccurate claims processing.

It should be taking all data available and pushing solutions upstream. Maintaining a prepay strategy that's well documented and well managed by a payment integrity leader will keep all key stakeholders moving in the right direction.

Host: How do we overcome barriers to moving our strategy?

Erin: It really starts with vision and alignment. Get back to the basics, including setting up meetings and start communicating about what you want to accomplish. Select a payment integrity champion who's going to lead your payment integrity journey and who will help establish some very clear success criteria. It's essential to a quality payment integrity program to establish clear and quantifiable success criteria. Having that in place allows you to measure the performance of all aspects of an enterprise payment integrity program.

Once you establish that regular cadence for those assessments and you get that buy-in from key stakeholders, then you're able to really identify and document trends and begin to put action plans in place, or partner with key vendors to make meaningful change in the areas where you need it most.

Host: We don't have internal resources to devote to this. What should we do?

Erin: Look for a vendor partner or engage with a consulting firm who can help you start moving. Look for partners who offer comprehensive analytics and who offer both software and services as well as consulting. Using service providers will help simplify your ability to assess how your program is doing by shifting the responsibility to your partner for the dashboard style reporting, and for ongoing management of key metrics that you determine together.

Whether it's a long term partnership or one that just gets you started before you can justify resource allocation, it's a great place to start. When selecting your partner, pick one who offers more than just postpay solutions or more than just prepay solutions. Select partner who's incentivized to move from pay and chase up to prepay avoidance. In addition to all of the financial benefits of consolidating vendors, it will also reduce provider abrasion by reducing multiple entities going after the same providers.

Whether it's a function of investigation, identification or recovery, managing a vendor carries certain costs, and many plans don't have a consolidated view of what they're really spending across the payment integrity spectrum as well as what opportunities exist to reduce the number of vendors. Selecting a vendor that can do more than one thing and do them very well will certainly increase efficiency and reduce administrative costs.


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In the final podcast of our two-part series: Erin Schmuker, vice president of product solutions, Optum Payment Integrity, discusses how pre-payment activites can be integrated with existing post-payment efforts to create a comprehensive payment integrity strategy.