The Path to Point-of-Service Payment Success: Integrated Ecosystems

Greg Burgess, President and Chief Product Officer, spoke at the 2019 AHIP Institute & Expo on “The Path to Point-of-Service Payment Success.” Below is the second in a series that dives deeper into the advancements in technology that will bring us closer to accurate point-of-care payments in healthcare.

A routine annual wellness visit should be simple for a health plan to pay. But too often, after the claim has spent several days being reviewed in your claims system, a final check reveals a coding error. Say for example, a separate and distinct service, like a strep test, occurred at the time of the visit, and caused the entire claim to be rejected because it was not properly billed. Now, staff must invest time adjusting the claim manually. And that’s for a single, straightforward claim. We all know how fragmented, inaccurate, and lengthy the life of a complex claim can become, especially when errors are found after the provider has been reimbursed and you need to recover the payment.

Many payers today rely on multiple pricing, editing and other solutions within their claims payment system and are accustomed to the resulting improper payments. Gartner notes that improper claim payment is a pervasive and expensive problem with between three and seven percent of all healthcare claims paid inaccurately. More alarming, the percentage of inaccurate payments can be as high as 50% for specific services, such as CPT code 99233 for Level 3 initial inpatient hospital admission encounters. 1   

With multiple systems that rely on manual intervention, infrequent data and policy updates, and disconnected communication systems, it’s no surprise that inaccuracies persist. When payments are made based on inaccurate data, additional time and energy is spent recovering that revenue.

But what if, on the path to point-of-service payments, we addressed the root of these inaccuracies and thought of the claims payment system as a whole—as a cohesive system where software, data, and service platforms are brought together in an integrated ecosystem? What if claims payment transformation was a priority and not an afterthought?

Taking a modern approach

Traditional claims payment systems are disjointed and require substantial workflow management and manual effort which increases operational overhead costs and creates uncertain results. Alternatively, an integrated ecosystem eliminates communication errors, delivers prepayment accuracy, and lessens the odds of human error. Ecosystems provide streamlined, actionable results to your health plan, and open doors to refocus the time and effort of your staff.

If payment operations transformed into integrated ecosystems, the process could look more like the connected devices and services offered by your mobile device company. Think about how your smartphone, operating system, music apps, cloud backup, and even your streaming video work together—they communicate seamlessly, share data, and ultimately deliver desired results. This platform goes further, though, by incorporating disparate apps into a single ecosystem. With the press of a button (or swipe of a screen), you can easily use this one platform, accessed by your phone, tablet or computer, to fill multiple functions in your daily life.

On the path to point-of-service payment success, we need to consider integrated ecosystems that offer a single instance and extensibility—much like the smartphone system—to incorporate all the functionality of your complex payment operations, but with streamlined communication, centralized data, and connection to third-party platforms, all of which are crucial to realizing point-of-service payments. To make the important decision to move toward this end state, we must first understand the components of an integrated ecosystem and how it operates.

What are the benefits of an integrated ecosystem and how do we get there?

With traditional systems relying on many disparate parts, how do we move toward an integrated ecosystem? The transformation starts with enterprise-wide support on the path to point-of-service payments, with stakeholders backing technology that enables accurate and more instantaneous results. A significant step to addressing these initiatives begins with the adoption of single instance solutions.

Single instance solutions are designed to natively incorporate several functions that all work together, connecting to multiple claims systems while delivering streamlined and consistent results. When disparate functionalities like editing, pricing, and business intelligence are brought together in a single solution, it eliminates communication errors that often occur between systems not natively built to work together.

Additionally, single-instance solutions relieve the uncertainty of results stemming from the use of multiple service providers who operate under different missions and values, technologies and infrastructures, update cycles, and maintenance plans. Instead of having to perform checks in several systems or call multiple support departments, staff who work in claims, audit and provider relations, or medical management have all the information they need to do their job in a single source.

Single-instance solutions should also be extensible to ensure that you, the payer, are getting best-of-breed data and functionality. Just as you would add various apps to your mobile devices, extensibility allows the inclusion of third-party solutions with no compromise in quality. Incorporating other leading solutions into a larger and more consistent workflow creates an integrated ecosystem for seamlessly applying your policies and business rules to your claims.

Furthermore, when claims payment processes utilize integrated ecosystems, claims data is more accurate and readily accessible to enable actionable, predictive analytics. This real-time data considers all aspects of the claims payment process and delivers enterprise-quality results that can be advantageous. These results impact future decisions like new product launches, acquisitions, and commercializing services in the marketplace, giving you the unique ability to plan based on proven what-if scenarios.

Ultimately, an integrated ecosystem functions like a funnel, taking disparate solutions with disjointed data and delivering a single, accurate outcome—an essential component of enabling point-of-service payment success. Integrated ecosystems relieve health plans and payers of a myriad of burdens, including administrative overhead, inaccuracy, and the need to recover costs, while empowering powerful business intelligence.

Point-of-Service Payment Success

For health plans currently using a traditional approach to claims payment operations, developing an integrated ecosystem requires significant transformation, not just of the disparate point solutions, but of your entire organization and how you approach payment integrity. Integrated ecosystems depend on extensible, single-instance technology solutions, as well as investment by internal stakeholders in the end goal—point-of-service pricing.

While encouraging the internal support needed to revolutionize the claims management process may not be easy or straightforward to do, the benefits of doing so are vital, not only to members receiving care, but to health plans and providers as well. A greatly simplified and accurate process leads to better relationships with providers and members, an improved bottom line, and actionable data that you can use to forecast future business decisions.

According to a recent Gartner analysis, payers are more careful about modernizing their administrative systems than what we see in almost all other industries (including auto or homeowner’s insurance). They tend to choose to upgrade systems currently in place rather than tackling larger efforts to modernize the process. However, ecosystems will help your enterprise scale and innovate. If you don’t have the ability to support these ecosystem approaches, you will severely limit the enterprise’s growth aspirations. 2 

When we consider the time and money spent working to pay a claim correctly—even a simple one like an annual wellness visit—there’s no question that change needs to occur. But who is responsible for fixing this system and creating the ideal solution? Simply put, the payers and technology providers in the healthcare industry have the unique power to push the industry forward. We are responsible for envisioning this solution and making progress toward it.

With our data in the cloud and an integrated ecosystem implemented, we are ready to dive deeper into the final key to point-of-service payment success: process automation and intelligence.

Interested in reading more? Subscribe now to get the next in the series, “The Path to Point-of-Service Payment Success: Process Automation and Intelligence” via email.

1 Gartner, Hype Cycle for U.S. Health Payers, 2019, Published: 18 July 2019

2 Gartner, Survey Analysis: U.S. Healthcare Payers’ Legacy Modernization Is Not Complete, Published: 17 May 2019

About Burgess

Burgess is dedicated to improving healthcare payment operations through technology. We bring technology innovation and real-time data to an overlooked and critical part of the American healthcare system. Our scalable Payment Accountability® platform, Burgess Source®, integrates payer systems to transform payment workflows and provide powerful business intelligence to lift payer performance. The company is located in Alexandria, Va., with a satellite office in West Hartford, Conn., and online at burgessgroup.com.