Evaluating Payment Integrity Solutions for Health Plans

Some health plans and payers have attempted to develop internal processes to audit claims and identify overpayments. Others have multiple third-party applications, often implemented by different departments without a cohesive strategy. More often, organizations don’t have the time or resources to review all claims manually, and automating the process requires advanced data analytics to be effective.

Choosing a payment integrity solution or partner can be overwhelming if you’re a health plan administrator or stakeholder. That’s why Alaffia Health, a thought leader in payment integrity technology and implementation, is here to help! While many healthcare payment technology platforms promise the advanced, scalable data analytics necessary to identify and recover overpayments, not every solution is created equal. 

So how do you find the right partner to ensure you’re paying for the medical care your members need while still controlling costs? Let’s find out. 

Fraud, Waste, And Abuse

The U.S. health insurance industry loses an estimated $300 billion or more each year to fraud, waste, and abuse. For scale, that’s more than the GDP of 27 U.S. states — or all but the top 20% of countries. The FBI estimates that fraud alone accounts for 3–10% of all healthcare expenditures.

$300 billion is a big number, but in concrete terms for your organization? Fraud, waste, and abuse cost healthcare payers an estimated $650 per member per year. Reducing this cost is one of the biggest opportunities for health insurance organizations to improve their bottom line — and stay competitive. 

What To Look For In A Payment Integrity Partner

Many healthcare executives find that the most effective path to address overbilling is locating a partner that specializes in payment integrity with a proven, tested, and scalable technology platform. The healthcare field is an ideal place to deploy big data-driven solutions. Locating overbilling errors is a repeatable process ideal for AI platforms capable of machine learning and scaling to meet client needs. When deployed correctly, this equates to a higher recovery rate and an immediate boost to the bottom line. 

When looking to implement a payment integrity solution, whether internally or through a service provider, there are some key metrics to consider when evaluating your options. 

Easy Setup and Implementation

A payment integrity solution should be a place to save costs, not create them. Internal processes take time and resources to implement while depending on medical billing and coding specialists to locate claims means additional payroll costs. A strong payment integrity partner should implement their system and integrate it seamlessly with your payment systems at no cost to you. 

Cost Certainty

Every vendor and service provider can make big promises, but can they put their money where their mouth is? A great payment integrity partner will deliver on their promises by basing compensation on results. Look for a service provider that gets paid based on the overpayments they recover and prevent for your organization, not one that demands upfront or fixed costs without proving their worth. 

An Ounce of Prevention is Worth a Pound of Cure

It’s always best to proactively stop overpayments before they occur rather than attempting recovery. However, the window to make or deny a payment can be as tight as 15 days, leaving a narrow window to audit a claim and determine whether there’s been an overpayment. Choosing a payment integrity partner that analyzes, identifies, and clarifies overpayments quickly provides the opportunity to make an accurate payment the first time, with no need to seek recovery. A proactive approach also includes educating providers on best billing practices and building stronger relationships between providers and payers.

Trust, but Verify

Besides proactively auditing claims, a good payment integrity provider will review services rendered and billed to identify discrepancies and recover any overpayments. They’ll use data from claims and audits to continually analyze fraud, waste, and abuse trends. The best providers flag and intensively audit the high-cost claims that make up an outsized portion of claims expenditures and overpayments. They stay focused on areas statistically proven to contain fraud, waste, and abuse to ensure maximum savings for healthcare payers and their members. 

Automated Efficiency

Machine learning and artificial intelligence are key components of a technology-powered payment integrity partner. These emerging technologies enable faster, more thorough reviews of more claims than otherwise possible. A well-implemented system will contact providers independently to corroborate documentation on claims and even detect and track fraud, waste, and abuse patterns by each provider. This frees up time for fraud analysts and other team members to ollow up on potential overpayments.

Melding Expertise, Technology, and Methodology

Big data can provide technical solutions to big problems, but technology is no remedy on its own. Truly effective solutions combine innovative technology with subject expertise and thoughtful methodology to achieve maximum results. After all, the most advanced analytics are meaningless without the expertise and experience to interpret them. Combining a technology platform that features machine learning, process automation, AI, and an experienced team of healthcare billing and coding specialists, fraud analysts, and medical experts leverages the best of both worlds.

Choosing The Right Solution

Protecting your organization from fraud, waste, and abuse is more important than ever with the rapid increase of healthcare costs — and complexity of healthcare billing — in today’s environment. Partnering with a proven leader in healthcare payment integrity provides significant advantages in scalability and flexibility compared to an internally developed solution. You can ensure a good fit by weighing potential partners based on relevant, mission-critical metrics.

Alaffia Health excels in the key metrics we’ve identified for a healthcare payment integrity partner. Our mission is to eliminate improper payments so that providers and payers can focus on what matters: providing the best care to patients at the best possible price. 

Easy Onboarding 

Alaffia’s platforms and workflows integrate seamlessly into the payer’s workflows and systems with no disruption to members. With our Payment-Integrity-as-a-Service model, we help healthcare payers recover and prevent overpayments immediately with swift implementation.

Contingency-Based Costs 

It’s easy to make big promises, but the tough part is delivering on them. That’s why Alaffia only gets paid for results. Instead of relying on a traditional payment structure, Alaffia retains a percentage of the savings generated for clients. Why? We’re confident in our technology, our people, and our approach. And it’s how we generate scalable, consistent, repeatable results. 

Proactive and Preventative Action 

Recovering overpayments is important, but never making the overpayment is better. Alaffia’s multifaceted approach addresses overbilling both proactively and retroactively. Our team parses claims data and proactively pursues supporting documentation to prevent overpayments and educate providers on proper billing. Meanwhile, our experienced analysts, with the help of AI support, conduct forensic analysis of existing claims and documentation to retroactively identify and recover overbilling. 

Targeted Auditing and Payment Recovery 

Alaffia uses analytics and domain expertise to zero in on claim categories most likely to contain high-cost errors, such as facility inpatient care. Domain experts audit claims and itemized charges, conduct a detailed forensic analysis, then send a detailed report to providers to establish the correct billing amount for each claim. Payers are then advised of the accurate amount — and how much Alaffia saved them over the original bill. 

Automation 

Alaffia’s proprietary technology uses machine learning, natural language processing, and other artificial intelligence applications as a force multiplier, automating repeatable, learnable actions to ensure accuracy, consistency, and efficiency. Our advanced data analytics provide real-time data about past and current claims as well as tracking fraud, waste, and abuse patterns over time, providing unparalleled insights. 

Technology + Expertise = Synergy 

Alaffia combines human expertise, next-generation AI technology, and a targeted, focused strategy for a multifaceted approach to healthcare payment integrity. Combining the insight and expertise of human analysts with the accuracy, efficiency, and pattern tracking of AI leads to unparalleled results. 

Proven Savings From A Proven Healthcare Billing Partner

Commercial health plans, government agencies, self-insured employers, and third-party administrators face enormous pressure to reduce fraud, waste, and abuse charges. Alaffia Health’s Payment-Integrity-as-a-Service platform provides an established, turnkey solution to address these challenges and make an immediate effect on the bottom line. 

We excel in each of the key areas we’ve identified for payment integrity partners and have audited some of the largest healthcare systems in the U.S., finding an average savings of $150 per member. With 100k members, that’s $15 million in potential savings each year. If you’re looking for a proven partner to deliver immediate results with minimal disruption and upfront cost, Alaffia Health checks all the boxes on the list. Get in touch with us today!

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