Imagine the sound of a record scratch.
Did you grow up playing your favorite music on vinyl records? No matter when you were first introduced to LP records, a record scratch is painful! When your diamond record needle races across your collector’s edition of your favorite artist, that record will never play the same again. That ugly piercing sound will live with that record forever. When the record gets scratched, that section of the track no longer plays. For audiophiles, it’s no fun at all.
A similar pain can occur within your Payment Integrity program.
Imagine spending weeks analyzing data and identifying cases of interest.
All of the approvals are in place to move forward.
Everyone is super pumped and ready to go.
The information request goes out to the providers.
The information comes back, the review begins and…
Every claim has supporting documentation.
They’re not falsified or duplicated across multiple patients.
They all line up but, now there’s nothing to move forward with.
Well, maybe something…
Four months were spent to get here between the back and forth with the provider and reviewing all that documentation.
The provider is mad as heck – threatening to drop out of the network. They spent all that time pulling records when they could have been seeing patients.
As a payer, the organization is spending valuable time, effort and resources trying to improve payment integrity – only to realize after the fact that the information was wrong. Worse yet – the relationship with the provider may be damaged and team morale is down.
The root cause of this scenario is something all too common – false positives, which lead to provider abrasion. In this instance, a false positive is a lead that appears to be a valid case that will produce a successful outcome (recovery), but the reality is that it’s not a valid case.
What can be done to reduce these false positives?
Just move on and hope the next one is better?
Within a Payment Integrity program, having accurate information is critical. It is important have a technology platform that provides the ability to gain a good understanding of the underlying data and analytics approach in order to ensure accurate conclusions are reached. Defining the outcome is particularly important as technology that supports a variety of analytical techniques is often used to identify cases of interest.
Lots of Payment Integrity programs leverage technology to solve the problem. Imagine an abundance of algorithms available for identifying leads!
The challenge with many technology solutions is that they are a siloed approach and fail to deliver both speed and accuracy. On the other hand, a Payment Integrity platform that provides a comprehensive and seamless solution that’s integrated and adaptable to how you work provides an opportunity to advance the capabilities of the Payment Integrity program. It’s especially important that the platform be powerful but easy to use allowing the Payment Integrity program to achieve the desired outcomes.
We hear from our customers all the time:
“Provider abrasion is a major problem in the industry.”
Bottom Line: False positives and provider abrasion go hand in hand. High false positives lead to high provider abrasion.
False positives over 1% can be an indication that something is wrong.
What is the business impact of false positives?
- Chasing false positives represents a lost opportunity for organizations, investigators, and providers. False positives decrease efficiency, morale, trust, and performance.
- Instead of potentially shutting down that next major fraud ring, those committing fraud continue to get paid and a real case with a valid recovery opportunity goes unworked.
- Team members get burnt-out from spending time working a lead and the result is that there was nothing there.
- Provider abrasion rubs the wrong way. Providers get frustrated because they’re losing time with patients (i.e., pulled away from improving health outcomes) and are spending more time on administrative activities (i.e., pulling records). Their time could be better spent working toward hitting the targets on value-based payment arrangements.
What can contribute to higher false positive rates?
- Data: What goes in defines what comes out. The only thing worse than no data is bad data.
- Configuration: A black-box approach to implementing analytics and algorithms can lead you down the wrong path quickly. Without knowing what the algorithm is doing, it can be tough to ensure it is implemented appropriately. For example, an algorithm designed for a commercial plan may not be appropriate to deploy in a Medicaid or Medicare environment. And even those that are appropriate across different payer types may require setting different thresholds for certain activities. Does your platform allow you to easily see “behind the scenes” and modify model parameters?
- Adaptability: Healthcare isn’t a “set it and forget it” industry. Things change constantly. While sophisticated unsupervised machine learning algorithms will continue to learn over time, other algorithms that are rule-based may become outdated as policies or coverage determinations change over time. Is there a feedback loop within the platform so that the algorithms learn from previous experiences and improve over time?
- Silos: Everyone in the organization has a role to play when it comes to Payment Integrity. Creating shared goals through cross-business collaboration can set the program up for success. Does your platform allow for collaboration across the organization while still maintaining appropriate access to information?
False positives can certainly create a strain on the relationship between providers and payers. No matter which team – recovery, investigation, audit – is conducting the work, if the platform is delivering high false positives, the provider abrasion will come along for the ride.
Leveraging a technology platform that enables the organization to access the right data, easily. configure models, adapt over time, and break down silos can lead to a much lower false positive rate. This high degree of accuracy will result in less provider abrasion and a more efficient Payment Integrity Program.
Like a vinyl record without scratches, reducing false positives increases the hi fidelity of your Payment Integrity program.