Survey of >100 health plan leaders offers insight into the challenges of balancing prospective and retrospective approaches across enterprise payment integrity programs
SALT LAKE CITY, July 6, 2021 – Cotiviti, a leader in data-driven healthcare solutions, has published new research capturing the healthcare payer industry’s challenges in optimizing pre and postpay claim payment integrity programs. The report, “Optimizing Payment Integrity with Enterprise Pre and Postpayment Solutions,” is based on a survey of 104 health plan stakeholders from more than 70 different payer organizations, conducted in partnership with HealthPayerIntelligence.
Among the key findings are:
“Health plans are increasingly finding that catching potential errors before claims are paid improves their financial performance by reducing overpayments while minimizing provider abrasion,” said Jordan Bazinsky, executive vice president of Cotiviti. “However, finding the right balance between retrospective and prospective payment integrity remains a challenge, and is frequently hampered by insufficient resources and lack of coordination among payment integrity vendors. This report ultimately confirms that payers need to take a unified, enterprise-level approach to payment integrity by deploying the right solution at the right time and removing silos between their pre and postpay teams and programs.”
Just 21% of surveyed health plan leaders say that more than half of their payment integrity is currently performed through prepayment intervention, though that figure is expected to rise to 30% within the next three years. The survey also found 54% are currently performing prepay intervention for coordination of benefits; 43% are performing prepay manual review of professional and outpatient claims with the member’s medical record; and 37% are performing prepay fraud, waste, and abuse detection.
In addition to misaligned vendors, major challenges health plans have encountered in implementing prepayment strategies were COVID-19 disruption (70%), risk of provider appeals (28%), insufficient resources (27%), and misaligned incentives between pre and postpay teams (25%).
“The biggest barrier [to prepay intervention] would be making sure we get efficient processes through our systems and that we don’t disrupt the payment model too much,” stated one managed care plan’s chief financial officer who was interviewed as part of the survey. “We’re looking for automation as much as possible. We’ll probably invest in a few more staff resources, but for the most part, we’re going to try it from an automated standpoint.”
Cotiviti is a leading solutions and analytics company that is reshaping the economics of healthcare, helping its clients uncover new opportunities to unlock value. Cotiviti’s solutions are a critical foundation for healthcare payers in their mission to lower healthcare costs and improve quality through higher performing payment accuracy, quality improvement, risk adjustment, and network performance management programs. Cotiviti’s healthcare solutions are powered by Caspian Clarity, a proprietary data and analytics platform spanning thousands of unique member and provider data types across financial and clinical domains, representing the most comprehensive longitudinal data set in healthcare. The company also supports the retail industry with data management and recovery audit services that improve business outcomes. For more information, visit www.cotiviti.com.
Aria Marketing for Cotiviti