Perspective
How Pre-Submission Improves the Provider-Payer Relationship
Summary
Pre-submission of medical claims reduces friction and promotes collaboration between providers and payers.
Perspective | Dave Cardelle
VP of Payment Integrity Solution Management at Change Healthcare
In today’s healthcare environment, both providers and payers are under enormous financial pressure to operate more efficiently, while delivering great service to healthcare consumers. All the while, providers and payers continue to spar over how to align payments with services rendered. It’s a frustrating—and costly— situation for all involved.
Everyone wants payment accuracy. The only question is, when is the best time to align providers and payers: before or after a payer has reimbursed a provider? Should the focus on payment accuracy occur pre-payment or post-payment?
The truth is that there’s a third approach. As an industry we should focus on getting it right from the get-go. It’s not just pre-pay or post-pay. Accuracy should start before a claim is even made. Potential savings rely on the exchange of information before a provider makes a claim.
That’s the pre-submission approach. Pre-submission makes the provider-payer relationship more transparent. It makes providerpayer interactions more collaborative. And it has the potential to transform the healthcare industry.
Payment Accuracy and Reducing Claims Errors
Pre-submission has the potential to become an important component of payment accuracy, which is itself a more encompassing approach than payment integrity. Payment integrity has long focused on reducing fraud and abuse.
Payment accuracy is a broader concept. Its goal is the reduction of errors in the entire reimbursement process, whether they are intentional or not.
When you know you have fewer errors, administrative costs for both providers and payers go down. There’s less pressure to test a claim’s validity via audit. Payment accuracy is about getting things right the first time, right out of the gate. Pre-submission lies right at the gate.
Traditional audit and recovery increases costs and administrative burdens. Payers ask for a set volume of medical records. Providers have responded by gearing up and maintaining staff and resources to comply with these requests. The higher the volume of requests from the payer and auditor, the greater the burden—and friction—from the perspective of the provider.
Of course, the auditing function will continue to be necessary and valuable. But there are limits on what can be audited, and how much can be audited.
Moreover, reimbursement recovery has become an ever-increasing component of payer revenue. In the case of high-value claims, for instance, the industry has built an army of auditors, rolling up their sleeves and digging into medical records, sometimes 300-, 400-pages thick, to find errors.
The truth is, given the number of claims out there, that both parties are limited as to the number of audits they can do or the number of records they can work with.
If the industry reduces administrative burdens and costs, accounts receivable and cash flow improve for both the provider and the payer. Moreover, the industry more easily can fulfill its fiduciary responsibility to reimburse providers for services delivered.
That’s not a new concept, especially as more employers elect to become self-insured and government entities strive to identify and recover overpayments. But there’s also competitive pressure as providers and payers continue to consolidate, and the healthcare industry becomes more complex.
Parts of the industry have moved from post-pay audit to pre-pay. That’s created more pressure on providers to produce medical records on a timely basis.
In some cases, payers default to technical denials which result, initially, in no payment—the equivalent of 100% recovery. Technical denials occur for many reasons. For instance, a provider may not have produced a particular record in time even though they may have fulfilled their obligation to deliver a service. The result: even more abrasion between provider and payer.
Pre-Submission Means Getting It Right The First Time
If both providers and payers agree ahead of time on how they’ll deal with errors, it gives the provider a chance to address issues and dispute findings before a payer moves to recovery.
Pre-submission analysis gives providers control by providing time to help solve payment issues. Most providers will abide by that approach if given a chance, and if they know they may not have to go through an arduous audit process.
The way to do this is to take large historical claims data sets and analyze patterns. That means taking learning that was derived from the post-payment view of a collection of claims, and applying that knowledge to anticipate challenges. This occurs at the beginning of the claims process. It takes postpayment learning and gives information that’s beneficial in a pre-submission scenario.
The traditional audit findings that we glean from DRG, hospital, specialty pharmacy, and other requests for reimbursement provide a blueprint for how to find problems. The industry can also leverage pre-submission data insights to take low-value, high-volume E&M services and look for incremental savings for a health plan, even where there may have been no previous audits.
Pre-submission takes sophisticated audit screening and combines it with data mining techniques. Presubmission allows the industry to pinpoint early on where there may be something potentially wrong with a claim. That’s post-payment logic and analysis applied before a claim is made.
The idea is to integrate post-payment learning into a clearinghouse platform. If a claim comes in that needs adjusting, the system can deliver in real time or near real time a message to the provider.
The system prompts the provider to look more closely at a claim (maybe it was coded incorrectly, for instance) before the payer receives it. The provider has a chance to verify the claim and resubmit it. The result: far fewer claims are denied; far fewer claims need to be audited.
How Post-Payment Data Helps Pre-Submission
Here’s an example. Say you’re working with a specialty pharmacy and you know that there’s a $4,000 drug and there should be 10 units prescribed based on a particular diagnosis. If, pre-submission, a request mistakenly comes in for reimbursement for 100 units, a pre-submission system can take years of post-payment audit and recovery data and send a message back to the provider questioning the prescribed volume in the claim.
The provider then can correct the claim before it’s submitted. The provider receives information about the mismatched data immediately. And that translates into a tangible benefit with regard to the speed of reimbursement.
Pre-submission is particularly effective when the content resides in a cloud-based delivery system. Hosting the software onsite is labor- and resourceintensive. It’s difficult to keep the content updated.
A health IT vendor can provide updates and changes which payers may not have had the time to input. The idea is to provide a platform for a pre-submission feedback loop and deliver these data insights and collaborative messages directly into the provider’s billing workflow.
It’s important not to think of such a platform as a point solution. The process is far more holistic. It’s end-to-end, all with the goal of delivering an accurate bill.
The process starts before a claim is made, and goes all the way through to post-pay audit and recovery. It can embrace pre-submission, prepayment, and post-payment approaches. In this cohesive approach, the audit process provides an opportunity to review the history of the claim, identify patterns, and further improve efficiencies.
But the key is to give the provider the information so that they can respond and potentially adjust claims at the point of submission. For those who don’t adjust the claims, there’s still the possibility of recovery of incorrectly paid claims through post-pay auditing.
An end-to-end approach that begins with presubmission reduces overall abrasion. The vast majority of providers will adjust their claims submission behavior if they have the right information ahead of time. The whole process rewards providers because it leads to fewer audits.
Most claims are paid in good faith from the perspective of both the provider and the payer. Increasing transparency with pre-submission information will help the healthcare industry operate more efficiently. and give providers more time to do what they’ve been trained to do: work with patients and other healthcare consumers.
That helps everyone—whether pre-submission, prepayment, or post-payment—assess the probability that a given claim is an outlier. If a questionable claim passes muster, a payer might not have to request medical records or perform an audit. The result: reduced healthcare administrative costs and improved provider-payer relationship.