CMS Progam Integrity Assessment
A non-for-profit regional health plan brought in the Change Healthcare Consulting Team to complete a payment integrity (PI) assessment. Although payment integrity activities occurred within multiple departments, the plan lacked standardized metric reporting. The health plan had no overall corporate targets in place nor a consistent methodology for identification and reporting of results. The client asked the Consulting Team to complete an end-to-end evaluation of its current processes, compare and contrast its operations against industry standards, and provide recommendations on establishing metrics, expanding opportunities for additional areas of review and investigation, and ensuring overall program compliance.
The consulting team discovered a variety of opportunities for improvement in areas that were rife with inefficiencies, causing profit loss and creating additional work for team members. These challenges included:
This customer struggled with lower recovery rates due to departmental disparity with its Payment Integrity Program(s). The team offered multiple recommendations and approaches to address and solve these issues.
Following an enterprise Payment Integrity assessment and problem identification tactics, the team provided various recommendations, including:
The Change Healthcare Consulting team also helped the client implement new solutions to: