Payment Integrity Insights

Artificial intelligence (AI) and machine learning can help payment integrity programs achieve higher levels of value. But these technologies are not quick fixes and require proper planning and governance. Payers need to ensure that AI and machine learning are used in a way that supports their objectives and principles while improving member and provider satisfaction, not decreasing it.

On the sixth episode of Cotiviti’s Payment Integrity Insights podcast, Cotiviti’s Brett Arnold, senior vice president of product development, is joined by Anandhi Periyanan, senior vice president of R&D, to continue our conversation on the role of AI in payment integrity. Listen as Brett and Anandhi discuss these four key tenets to incorporating AI into payment integrity responsibly:

• AI is a tool, not a solution.
• AI should be used to improve your results.
• AI must be used responsibly.
• AI does not replace human expertise.

As health plans look to artificial intelligence (AI) and machine learning to improve their operations and payment integrity programs, they must understand how it can be practically applied. But payers also want to be reassured the technology will be adopted appropriately and responsibly—and won’t increase provider abrasion.

On the fifth episode of Cotiviti’s Payment Integrity Insights podcast, Cotiviti’s Brett Arnold, senior vice president of product development, is joined by Anandhi Periyanan, senior vice president of R&D, to discuss the role of AI in payment integrity. Listen and learn:

• How Cotiviti uses AI responsibly to increase payment integrity value
• How healthcare payers are using AI and the challenges they’re facing
• How to separate fact from fluff when evaluating AI partners

A successful coordination of benefits (COB) program can decrease medical costs, improve member relations, and avoid provider abrasion by quickly determining the correct order of benefits for even the most complex claims. But many payment integrity programs lack the necessary resources in bandwidth, data analytics, and business rules to coordinate benefit payments accurately and efficiently.

On the fourth episode of our Payment Integrity Insights podcast, Cotiviti’s coordination of benefits (COB) leaders discuss:

• The importance of having a comprehensive approach to COB to maximize value
• The differences between member-based versus claims-based strategies
• The limitations of relying solely on member eligibility data
• The strategies for optimizing COB programs, leveraging internal teams, member data, and the expertise of full-service COB partners to help ensure efficiency and savings

Amid rising medical loss ratios, administrative cost pressures, and increased competition, health plans are under pressure to deliver high-performing payment integrity programs. But when choosing between a software-only payment integrity vendor versus a full-service partner, health plans have many factors to consider when it comes to their prepay claim review, DRG validation, coordination of benefits, and data mining programs.

On the third episode of our Payment Integrity Insights podcast, Cotiviti’s payment integrity leaders discuss:

• The dimensions of payment integrity value that go beyond medical cost savings
• The benefits of pairing clinical expertise with advanced technology
• The value of consultative expertise including benchmarking and analytics

Many health plans choose to bypass editing on inpatient claims due to their complexity—but this means they potentially spend millions of dollars improperly in this rapidly growing area. While inpatient claims editing is challenging, with the right technology and expertise in place, payers can execute DRG and other inpatient claim reviews more efficiently while minimizing provider abrasion. In fact, this can often be accomplished even without requesting the member’s medical record.

On the second episode of our Payment Integrity Insights podcast, Cotiviti’s inpatient claim review experts discuss:

• How to increase postpay review efficiency for inpatient claims while also moving to more prepay for increased savings
• How artificial intelligence-driven chart selection can target medical records with the greatest likelihood of returning value
• How postpay cross-claim clinical review and certain prepay review types enable accurate determinations without a medical record

As self-insured employer groups, or administrative services only (ASO) partners manage a growing percentage of the commercial population, the pressure and demand for them to have visibility into payment integrity measures implemented by the administering plan is growing. On the first episode of Cotiviti’s new Payment Integrity Insights podcast, we dive deep into best practices and challenges in ASO payment integrity.

Listen to the episode and learn:

• How to decide on an opt-in versus opt-out approach
• How to communicate the value of payment integrity for self-funded employer groups
• How to support employer groups in implementations and reporting