The 2024 Cotiviti Client Conference (CCC24) brought together more than 140 health plan leaders to downtown Austin, Texas this month, highlighting new and creative ways for payers to solve healthcare’s evolving challenges. As payers, providers, and consumers alike deal with the implications of higher medical costs, inflation, increasing utilization, changing demographics, escalating chronic care incidence, and new mandates, Cotiviti’s clients took part in robust discussions to share innovative ideas aimed at solving these challenges.
Here are three takeaways from CCC24 to enable health plans to navigate new frontiers in healthcare.
Transparency in payment integrity is increasingly vital
As healthcare systems continue to consolidate and we all feel the impact of rising inflation across the board, providers are increasingly looking to limit or remove payment integrity measures, potentially leading to inappropriate and wasteful spending. Understandably, providers also want more insight into how payment policies are applied by the health plan—as well as explanations of the rationale behind those policies.
To improve the acceptance and sustainability of their payment integrity programs, payers should look to improve the transparency of their payment policies with providers in a sustainable and scalable way. An effective strategy includes several components, such as:
- Proactive provider education when introducing a new policy
- Policy modeling tools that enable a provider to ask, “If I submit this claim, which edits will be applied?”
- Clear explanations for each claim that was edited, accessible on demand by the provider
Implementing this level of transparency will go a long way toward correcting future billing behavior and reducing recurrence of inappropriate claims—and just as vital, it will improve the provider experience and overall relationship with the health plan.
In addition to external transparency, many payer organizations would also benefit from improved internal clarity across their payment integrity initiatives. With separate teams often dedicated to programs such as prepay claim editing, DRG review, and coordination of benefits, it’s difficult for health plan leaders to look at the big picture to determine the cumulative effectiveness of their many payment integrity initiatives. By deploying high-level analytics presented through dashboards, spanning both prepay and postpay programs, payers can gain a clear view of which payment policies are driving improved payment accuracy—and which policies may require additional provider education and communication.
Providers and members can’t be left behind by digital transformation
Cotiviti’s discussion with the National Committee for Quality Assurance (NCQA) offered a valuable opportunity for CCC24 attendees to hear directly from the organization on its plans to transition to digital-only HEDIS® measurement by 2030. This goal is aimed at driving more efficient data collection and reporting by reducing the need for burdensome tasks such as medical record requests. But as direct health plan feedback at CCC24 indicated, the entire healthcare ecosystem has a long way to go. For example, nearly 70% of audience members polled at the discussion indicated their organization does not yet have a complete plan to implement the Fast Healthcare Interoperability Resources (FHIR) standard.
Beyond payer readiness for digital transformation, provider readiness is also a significant challenge. One health plan quality manager noted that the majority of her plan’s providers in a largely rural state are still submitting paper claims. In addition, providers are struggling to transfer data over the FHIR standard, particularly when constant updates and re-coding are required.
Most important of all, health plans must ensure that vulnerable members are not left behind when transitioning to new digital strategies. One health plan executive noted that her organization was struggling to determine why members of a local Native American tribe were not seeking preventive care—until the plan conducted a face-to-face listening session with the tribe and learned about its struggles with transportation. In an age where email and text messaging are taken for granted, her story served as a valuable reminder that getting out of the office and into the community is often the best way to understand members’ needs.
Artificial intelligence requires a scalable, responsible approach
The promise for artificial intelligence (AI) in healthcare is tremendous, potentially saving hundreds of billions of dollars per year in wasteful spending—with generative AI saving perhaps hundreds of billions more. From enabling payers to reduce medical record requests by targeting the right charts with advanced analytics, to empowering providers to drastically reduce time spent on documentation, to improving healthcare outcomes for consumers by generating targeted messaging that will resonate with them, AI has numerous use cases that can improve outcomes for every healthcare stakeholder.
Yet we all know that a tremendous amount of anxiety exists around AI as well. Providers don’t want the technology to be used to increase claim denials. Consumers are concerned about how their data will be used and whether AI models could be biased against them.
Health plan leaders must begin by recognizing that AI is a tool—not a solution. Rather than using AI to replace clinical expertise, it should be used to augment that expertise. For example, natural language processing can empower risk adjustment coders to code charts more completely, delivering increased accuracy, value, and consistency. Machine learning can enable healthcare fraud investigators to identify patterns of inappropriate billing across multiple payers that would be impossible to identify with traditional methods. By strategically prioritizing specific use cases for AI, adopting responsible guardrails, and managing risks appropriately, payers can enhance their effectiveness with AI-driven solutions, delivering better outcomes for their members and provider networks.
As we also discussed at CCC24, critical to navigating new frontiers in healthcare is a robust interoperability program, enabling payers to rapidly and securely acquire data contained in medical records to support essential functions. Read our recent white paper by Katie Devlin, DHSc, MS, CPHIMS, Cotiviti’s vice president of interoperability, and learn the critical elements of:
- Acquiring data from providers and data partners
- Ingesting data and performing normalization and enrichment
- Executing data standardization and storage
- Integrating data with downstream applications
HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA).
