Persistent inequities in care supply and outcomes. Inefficient processes and siloed methods that don’t talk with each other. Spending probably the most on the planet with out attaining the most effective outcomes. These are just some of the U.S. healthcare issues that greater than 100 Cotiviti purchasers got here collectively to deal with final week in Charleston, South Carolina on the 2022 Cotiviti Shopper Convention (CCC22).
Whereas these challenges could seem insurmountable to some, our expertise on the convention demonstrated there are numerous causes to be optimistic that healthcare stakeholders can make significant progress in fixing these issues by means of collaboration, innovation, and rigor. Listed here are 5 highlights from CCC22 that Cotiviti will deeply concentrate on within the coming 12 months to drive higher outcomes for our purchasers and their members.
To deal with healthcare inequities, well being plans should do higher at member engagement.
One among my favourite audio system of the convention was a pacesetter of a significant southeastern payer, the most important in its state. Drawing on his expertise as a supplier, he mirrored on the way it’s simple to dismiss sufferers who miss an appointment as “no-shows.” However when he spent extra time in his area people, he realized that healthcare organizations typically don’t take into consideration how a affected person won’t have cash to place fuel of their automotive—or fairly actually have to decide on between refilling a prescription and placing meals on the desk.
As this speaker put it, well being plans at the moment are starting to understand that they will “do nicely by doing good.” This goes far past sending members a textual content message to remind them of upcoming appointments. It means paying for them to catch a Lyft for follow-up care. It means partnering with native meals banks to scale back meals insecurity. It additionally means bringing care on to members the place they spend time locally, reminiscent of laundromats or libraries, and understanding cultural nuances that transcend language when reaching out to members.
Plans are additionally realizing that by growing technology-driven collaboration between inner departments, reminiscent of care administration and member companies, they will make significant progress in closing care gaps. One shopper in New York famous that since launching a program enabling its member companies brokers to have care hole data at their fingertips, it has seen a virtually tenfold improve within the quantity of dialog it’s having with members about closing their care gaps.
Participating Medicaid members to take motion
Payers should look to growing applied sciences and exterior partnerships to innovate quicker.
Let’s face it—implementing large-scale IT initiatives at most organizations is gradual and cumbersome. Well being plans typically have a backlog of inner initiatives to slog by means of earlier than they will take into consideration constructing new capabilities in-house, and safety considerations typically push organizations to deal with huge quantities of knowledge on-premises utilizing antiquated methods.
As offered by my colleague Nicole Neumarker, govt vice chairman of growth and innovation, healthcare organizations are more and more seeking to automation and no-code or low-code applied sciences to vastly enhance pace to innovation. This empowers enterprise leaders within the group who possible don’t have programming experience themselves to grow to be “citizen builders.” Payers are additionally turning to more and more safe cloud-based options that allow them to let go of the wrestle to keep up a convoluted assortment of on-site information warehouses and put in software program. In an atmosphere the place quite a few crucial packages reminiscent of fee integrity, danger adjustment, and high quality enchancment typically compete for inner sources, this strategy can enhance speed-to-value throughout the enterprise.
Fixing fee integrity challenges requires wanting past prepay vs. postpay.
Historically, claims fee integrity has been divided into two easy buckets: prepay and postpay. However such a siloed considering has led to competing incentives and suboptimal outcomes. As a substitute, the optimum strategy is to think about fee integrity as what we name a linked declare continuum, the place fee integrity challenges are organized by the character of the issue and how you can resolve it somewhat than an arbitrary timeline.
For instance, at Cotiviti, we don’t have separate groups for prepay and postpay medical chart assessment or coordination of advantages validation. As a substitute, we’re a single workforce targeted on shifting worth ahead within the claims fee course of wherever we are able to. By aligning processes, supply mechanisms, and execution inside their organizations, payers can concurrently enhance fee integrity financial savings whereas lowering supplier abrasion.
Past healthcare fraud, there may be extra alternative to forestall the “in-between” challenges of waste and abuse.
The “F” a part of FWA typically will get probably the most consideration, and it’s not onerous to see why. Dangerous actors will sadly at all times be part of our healthcare system, and the painstaking work achieved by particular investigative items (SIUs) in collaboration with regulation enforcement will stay very important. However whereas it won’t get very many headlines, extra may be achieved relating to stopping waste and abuse from suppliers.
As famous by one in every of our purchasers, an SIU director, supplier training reminiscent of right coding initiatives can go a good distance towards stopping future inappropriate claims. In any case, suppliers need their claims to be paid promptly. Throughout their day by day auditing and information mining processes, payers can start to detect patterns and see the place their supplier community would profit from coding training with an eye fixed towards correction and collaboration, not punishment.
Well being plans should get forward of shifting websites of care.
By now, everyone knows that the explosive progress in telehealth pushed by the COVID-19 pandemic shall be a long-lasting a part of our healthcare system. However equally essential is the expansion of healthcare supply in different settings exterior of inpatient care, together with at house, at ambulatory surgical facilities, and in retail settings, the place many types of main care may be delivered in an atmosphere the place shoppers are used to buying groceries or different home items.
Finally, delivering care in these lower-cost settings shall be useful for our whole healthcare system. Nevertheless, payers have to be vigilant in making certain that the standard of healthcare supply in these settings will increase, not decreases. These various websites of care shouldn’t be seen as merely a solution to include prices, however somewhat a possibility for payers to achieve their members proper the place they’re.
Regardless of the numerous challenges that stay within the U.S. healthcare system, CCC22 demonstrated that when healthcare organizations collaborate, super issues may be completed. Now we have already built-in many of those learnings from CCC22 into our day by day operations and sit up for partnering with our purchasers to make a significant distinction for all stakeholders in our healthcare system.
With the typical Medicare Benefit (MA) beneficiary having 39 plans to select from in 2022, the competitors is getting even harder—and plans that haven’t taken benefit of each alternative to drive danger adjustment excellence will fall behind.
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