When the COVID-19 pandemic accelerated rapidly in early 2020, the impact on healthcare utilization was sharp, dropping nearly 32% in April 2020 as both providers and healthcare consumers quickly moved to delay or cancel elective procedures. As noted by the Peterson-KFF Health System Tracker, this continued into 2021, with approximately one in five adults continuing to miss or delay medical care, and by some metrics utilization remained below pre-pandemic levels even into 2022.
Now, the federal COVID-19 Public Health Emergency is officially over, public health restrictions have been lifted, healthcare staffing has rebounded, and more vulnerable healthcare consumers such as seniors are growing increasingly comfortable with receiving care. This means that health plans are realizing the impacts of the pent-up demand that accumulated during the height of the pandemic and beyond, with the largest national payers readying themselves for a jump in medical costs due to higher-than anticipated utilization in surgeries and other procedures. The country is also experiencing an aging baby boomer population coupled with a bump in life expectancy and a more active senior population.
This increase in healthcare consumption is validated by Cotiviti’s own payment integrity data, which has shown year-over-year increases in both utilization and unit cost of several surgical procedures that far outpaced expectations. For example, for total knee arthroplasty, utilization is up 12% (versus overall utilization increases of just 1–2%) while unit cost is up 10%. For pulmonary vein isolation, utilization is up 17% while unit cost is up 11%.
While it’s undoubtedly a positive trend that healthcare consumers are catching up on necessary procedures and closing care gaps that widened during the worst of the pandemic, payers should consider several actions to help ensure they are paying claims accurately and appropriately amid this sharp increase in utilization. This ultimately reduces waste in our healthcare system, improves efficiency, and helps ensure that healthcare dollars are being spent where they can have the greatest impact. Here are four steps that can help health plans to achieve these goals.
The current rise in healthcare utilization and unit costs provides an impetus for payers to shore up their payment integrity programs. But make no mistake, it’s ultimately about paying the right claims accurately at the right point in the claim process to deliver better results for members, providers, and the plan itself.
Cotiviti works with more than 100 unique health plans of all sizes to improve the accuracy and integrity of claims payments, enabling our customers to reduce inappropriate medical costs by more than $8 billion in 2022. Whether you’re already deploying one or more of our Payment Accuracy solutions or have never worked with Cotiviti before, connect with our experts and see what value you may be able to realize.