Why Design Matters: Follow These Principles to Realize the Full Potential of Payment Integrity Software

by Frank Doto, Director of Client Services

Healthcare payers and software vendors have done the healthcare system a disservice in minimizing the importance of software design when evaluating their operational needs.

Complacency by the way of duct taping disparate systems together and sidestepping the labor-intensive design process impedes true understanding of workflow and hurts end user experience. If you aren’t thinking about design, the power of technology is stifled and health plans aren’t realizing full operational efficiencies which could save real dollars.

In 2014 market research firm TBR estimated $34.5 billion in healthcare IT spending alone, with the average payer’s IT budget valued at $18 million. The increasing relevance of digitized standards in the healthcare arena directly translates into a renewed demand for optimal technology solutions. Mission-critical claims management systems have arguably the greatest potential to reduce payer costs and eliminate widespread industry waste.

So why should design matter to a CIO? Several stakeholders within an organization – including Auditing, Claims Operations, Medical Economics, Compliance, Network Contracting, Provider Relations and IT – interact with network pricing and claims management software on a daily basis. A tool that effectively connects payment operations to the rest of the organization is a necessity, while simultaneously providing ease of use, efficiency, scalability, and cost savings. Only meticulously-crafted software with a focus on good design can seamlessly deliver on all of these demands with minimal IT maintenance and low Total Cost of Ownership.

Healthcare payers should consider the following when evaluating software systems that manage their claims operations management workflow.

Think about the larger ecosystem: Any health IT installation decision should view the system comprehensively, not as a string of singular parts. Software demonstrating a true understanding of your internal workflow will remove barriers to adoption, increase overall system productivity and significantly change how IT works for and within your organization. Good design connects people and departments by centralizing and sharing information, and making the everyday work experience more enjoyable. While most healthcare IT entities rally around simplicity, many platforms fall victim to only tackling a portion of the full adjudication process. This places much of the maintenance on the internal IT personnel. Great design fully incorporates the larger ecosystem with the smaller, individualized pieces of the process in real time.

Think about the future: Scalability and portability indicate resilient, adaptable software systems. Make sure the user interface can scale in functionality, content, volume, and number of users and that data is portable, and can be stored and accessed across multiple channels, claims systems, and periods of time. The best systems meet your needs today, but listen and constantly improve to meet tomorrow’s challenges.

Look to your workflow for savings: Claims systems, often patched together with a multitude of add-on solutions to satisfy end-to-end adjudication requirements, are the jackpot when searching for cost savings and operational efficiencies. Evaluate your workflow and document the various solutions you have for sourcing data and rate schedules, claim editing and the application of regulatory policies, network contracting and payment configuration, as well as claims reimbursement. Ask these questions when evaluating a new software solution.

  1. What is the development and update cycle? Payment accuracy is vital to cutting costs, as it reduces reprocessing costs, payment reconciliation costs, and costs associated with penalties. Ask prospect vendors to detail their development cycles to determine how they translate to system and data updates. Try to determine the gap between published regulatory and rate changes and their ability to make these updates available in their product. Then, assess which internal processes hinder the deployment of updates into production. There is a cost associated with tardiness, so ask potential vendors how they resolve this.
  2. How many different sources does your organization use to obtain the necessary data to fulfill cross-departmental needs? Data is the cornerstone component within a payer organization for accuracy, compliance and cost containment. Medical Economics uses current and historical data for trending analysis. Network Contracting departments need local, regional and national fee data to manage provider reimbursement schedules. Claims Operations and Provider Relations use fee and policy data every day to defend payments. In your organization, is there one source of truth or do you leverage multiple products, publications and websites to obtain your data consumption needs? A thoughtfully designed solution will provide your organization with a comprehensive data bank that can greatly reduce your cost overhead, and eliminate the common place struggles plans have with out-of-sync or conflicting data.
  3. Does the software allow multiple modes of automation? Automated claims processing is key to realizing operational efficiencies as it reduces overall processing costs; backlog costs, error reprocessing costs, and many other capital and HR costs. A well designed solution can connect in real-time as well as through batch processes. Great architecture will account for various data formats and technologies, such as 837 standards, flat file EDI, XML, and other formats. The very best automated solutions will be able to directly leverage the data, payment rates and rules derived from the one source of truth.
  4. Does the software have auditing capabilities? Compliance concerns are paramount within healthcare. Does the system allow auditing of payment and configuration changes? Can it provide claims and reconciliation reports? Can provider relations teams access records to defend payments? Does it provide other stats and audit features to keep you complaint?

Unearthing software that meets your business needs requires research and time. Focusing on smart design during this time will ensure you’re future-proof and the upfront cost will be offset by eliminating the need for an army of support professionals down the line. Utilizing just any software isn’t necessarily going to get you the results you want or need. But, investment in well-crafted software translates into efficiency, first-pass accuracy, consistency, and significant cost and time savings.

Frank Doto serves as the Director of Client Services for Burgess, the leader in payment integrity solutions for healthcare consumers of reimbursement data and information. He leads the Client Services Team in the development and maintenance of all integrated software solutions. His team provides strategic, technical, and clinical support for partner alliances, as well as delivers customized product solutions for individual client needs. Frank has 15+ years healthcare experience and is a seasoned professional in leadership, strategic direction, and administrative oversight.

Originally published on Becker’s Hospital Review/Becker’s Healthcare: http://www.beckershospitalreview.com/healthcare-information-technology/why-design-matters-follow-these-principles-to-realize-the-full-potential-of-payment-integrity-software.html