Why Payment Integrity Is Critical To Lowering Employer Health Insurance Costs

Program Integrity offers employers protection and savings

 

Maximize savings with industry-leading solutions

 

It’s estimated that about 3% of all healthcare spending is fraudulent, totaling tens of billions of dollars.1 That estimate does not include claims payment errors or waste.

 

Anthem’s Program Integrity (PI) services help identify and prevent claims fraud, abuse, waste, errors, and overpayments, providing employers a holistic, all-encompassing solution to help reduce unnecessary healthcare expenses. The ability to leverage advanced analytics and artificial intelligence (AI) alongside expert human reviews can deliver significant savings, especially in a complex and ever-changing healthcare environment.

 

Program Integrity Aligned Incentives (PIAI), our shared savings model, enables Anthem to take a proactive approach to minimize redundancies, streamline processes, and increase cost savings for our clients. Through advanced analytics and strong enterprise governance, PIAI ensures claim payments are:

• Correct (in accordance with the provider contract).
• Made to legitimate providers.
• For reasonable services.
• For eligible members.

 

PIAI yields a projected claims savings of $10-$12 per member per month.²

 

Employers receive 75% of recovered funds.

 

Our $25,000 cap means you’ll never pay more than that amount in fees for a single claim — even if Anthem saves more than $100,000 on the claim.

 

The five essential PI services and how they work together

 

1 Claims editing

Our proprietary algorithms help enforce reimbursement policies and ensure correct coding across each claim, identifying provider billing errors and preventing overpayments.

 

2 Data mining

Data mining reviews combine system-driven processes with human support, leveraging advanced anomaly detection to identify potential overpayments.

 

3 Complex clinical audits

Complex or high-dollar claims undergo line-by-line reviews, comparing them against medical records to ensure accuracy and adherence to claims guidelines.

 

4  Special investigations

A dedicated team of experts — including former FBI agents plus clinical and coding experts — investigates cases of suspected healthcare fraud, partnering with external law enforcement agencies.

 

5 Detection of other coverage

Proactive identification of dual medical coverage cases can clarify claims-payment responsibility and help drive significant savings for your organization.

 

What sets Anthem apart from the competition?

 

Robust support

2,100 employees dedicated to program integrity form one of the largest units in the country, spanning expertise across the complex healthcare environment. Different disciplines connect to offer a unified, seamless solution.

 

Integrated technology

Collaborative programs work together to gain synergies and enhance productivity. Manual interventions are minimized, workflows are streamlined and operational efficiencies free up resources.

 

Proactive efforts

Prepayments strategies aim to reduce the need for subsequent recovery efforts, which can be time consuming and costly. Savings are achieved by intervening before payment, reducing the difference between potential and actual payment amounts.

 

Recovery processes

Even after claim payments are made, monitoring helps catch instances of improper billing, where we then seek recovery of overpayment. Savings here equals the amount of recovered funds.

 

Advanced anomaly detection

AI and advanced analytics detect both simple and sophisticated attempts at abuse.  We predict suspect claims and proactively identify fraud, intervening before anomalies escalate.

 

Continuous improvement

We promote transparency and support by monitoring industry trends, providing provider education, and fostering collaboration to prevent future fraud. This includes better coding practices, enhancing documentation, and reducing errors.

 

Why are outsourced solutions ineffective?

Some third-party vendors offer program integrity solutions, but Anthem leads the industry with the size and scope of its program integrity solutions — using both human and technological capabilities.

 

Let’s look at some of the ways outsourced solutions don’t measure up.

 

Duplication 

Since PI is applied universally across both fully insured and self-funded clients, third-party vendor solutions duplicate the services Anthem already provides.

 

False positives 

Vendors do not access provider contracts and rely on industry standards to approximate deviations, resulting in false positives and wasted resources. Anthem compares claims directly to contracts to pinpoint deviations.

 

Inaccurate savings claims 

Vendor solutions lack full access to the lifecycle of a claim, so they aren’t aware if a change is made to the claim that impacts cost. We maintain integration protocols to ensure integrity and efficiency at every step.

 

Cost of integration 

Integrating claims data with vendors is time-consuming and costly, particularly as it is not maintained in real-time and can cause inaccuracies downstream.

 

Addressing symptoms, not root causes 

Detecting an error is not enough. We work directly with providers to provide transparency and education, enforcing policies that work to prevent future fraud, waste, and error.

 

We’re committed to program integrity and invested in protecting your bottom line ensuring that you avoid any unnecessary and avoidable spending.

 

With our unmatched data and analytics, along with a dedicated team of experts committed to program integrity, we cultivate continued enhancements to establish best-in-class capabilities.

 

1 NHCAA: The Challenge of Healthcare Fraud (accessed July 2023): nhcaa.org.
2 Program integrity internal program results, 2022.