“As today’s health plan market becomes more aggressive and markets narrow, payment integrity (PI) is taking on more importance as both a key challenge and an opportunity to improve efficiency, savings and member experience. Meanwhile, improper Medicaid payments, such as for ineligible patients or for services not provided, were estimated to be $36.2 billion in fiscal 2018, accounting for 9.8% of Medicaid spending…”
“A neutral, prospective approach to payment integrity should include access to secure, frequently updated health plan data on millions of members across the country. With this type of solution, health plans can quickly and reliably determine their own coverage responsibilities without needing to involve their members in the process, create provider abrasion and increase cost avoidance by as much as 31%…”
“Implement a neutral, prospective data solution. Health plans need a neutral, prospective solution with access to a national coverage database of health plan data, updated weekly. It should identify data for the exclusive benefit of the plan and should focus on using that data for claims payment prevention, rather than recovery. It should also…” Read the full post here.
Source: A $36 Billion Payment Integrity Problem… – By CAQH, March 23, 2020. HealthLeaders.
