Challengers of the Status Quo In Billing and Claims — More Accurate and Fairer Payment

Despite all the regulation, entrenched interests and bureaucratic entanglements, healthcare remains one of the more dynamic sectors of the American economy.

The activity spring partly from altruism: a desire to heal and help. There's also an abundance of resources — and not just a little profit seeking — in a sector that accounts for almost one-fifth of the U.S. economy.

Over the next few days, we are featuring some of the challengers to the status quo in U.S. healthcare: companies, people, trends and ideas that are shaking things up and reshaping the contour of how healthcare is paid for and delivered.

It's just a small sample - a tiny one - but these vignettes should provide insights into the road ahead in U.S. healthcare.

“Payment integrity is an area where we think we’ll see exponentially more growth, both prepaid and postpaid, and in training to help organizations keep the fraud from happening,” said Djariri.

When Sohail Djariri, chief growth officer at the business process management firm Sagility, thinks about the future, he sees the potential for dramatic change in an area that’s long been a problem. “Payment integrity is an area where we think we’ll see exponentially more growth, both prepaid and postpaid, and in training to help organizations keep the fraud from happening,” he says.

Payment integrity, which is a relatively new coinage in jargon-loving American healthcare, involves not only fraud detection but also coding corrections and error finding. It is a thriving niche in U.S. healthcare, where payers and providers not only constantly fight over bills and claims but also dream of a day when the trillions of dollars circulating through the system will flow frictionlessly.

Djariri says payment integrity businesses are poised to solve a problem that many view as beyond solving. One reason is technology. “I think we have more tools,” he says. “We have a lot more capabilities as an industry.”

Those tools include data mining and automated payment reviews that can provide insights alongside the more traditional, human-led clinical and coding audits. Powerful data analysis can be used to build models that forecast collections and overpayment, heading off problems before they happen.

Like many other areas in healthcare, payment integrity owes some of its ascendancy to the COVID-19 pandemic, which spawned a new generation of habits and ways of delivering healthcare. Sagility reported a spike in issues such as extended healthcare visit durations and early refills and disbursement of prescriptions during the pandemic. Telehealth led to new medical coding at a time when labor shortages and the shift toward remote work have also made it difficult for payers to keep up with the changes.

“There’s a demand and a huge need in the marketplace for this. The accuracy of payment — of what’s getting paid (and) what shouldn’t be getting paid — and doing it in such a way where you’re not alienating some of your constituents,” Djariri says.

Sagility says it handles approximately 8.78 million claim validations each year. The company works with both payers and providers, Djariri says, so company executives understand both sides of the claims coin: the frustrations of providers when they are denied or disputed and the frustrations of payers when they are inflated, coded inaccurately or outright fraudulent.

The company helps payers save close to a billion ($973 million) in savings and recoveries. Djariri says the point is not that payers are trying to evade paying for covered care but merely that antiquated and inaccurate systems create confusion that costs money. “It’s not that they don’t want to pay,” he says. “They just want to make sure they’re paying the accurate amount the first time instead of running around, chasing all that money.”

One final reason payment integrity is becoming an even more pressing issue is that consumers have increasingly high expectations for plans and providers, which means payment hiccups can quickly damage the brands of payers and providers. Djariri says payers have begun spending significantly to improve the consumer experience and bring transparency to claims and payments.