UM and prior authorization, which is the most commonly practiced form of utilization management, are both highly regulated, and health plans can face high penalties and fines when they are out of compliance. The existing US nursing shortage is another factor exacerbating the pain for payers who struggle to render decisions in a timely manner. At our December 6 AHIP-hosted webinar, key insights into the value of UMaaS were shared by Sagility’s Senior Vice President of Clinical Practice Krithika Srivats and Mike Van Den Eynde, Managing Director at Deloitte, including:

• Transformational intelligent automation and technologies
• Comprehensive UM process that maximizes efficiency, improves clinical care quality, and improves compliance to CMS mandates
• Clinician shortage mitigation
• Leveraging organizational capabilities in provider network quality
• End-to-end solution for a seamless provider experience and lower cost-per-auth

As part of the webinar, Sagility polled attendees and shared results representing key UM trends:

• For our poll regarding “What is your readiness to meet the CMS electronic and interoperability mandate?,” 75% of respondents are “In planning,” while 25% of attendees have a program “in development.”
• For poll two, “Do you have a comprehensive approach to your UM program?,” our attendees were evenly split, with one-third answering “Yes,” a third answering “No,” and the remainder with a “Partial approach.”
• Finally, with Poll 3, “Have you considered outsourcing your UM in full or part,” we determined that 50% of our attendees are not outsourcing but would consider doing so in the future.

With our post-webinar QandA session, Krithika and Mike provided critical insights into attendees’ questions.

Question: What are the technology requirements of the entity using the solution?

Response: We do think there are going to be some new capabilities needed to make this all work. There is more interoperability, and FIHR-based intake is going to be needed. Second, rules engine capability can do a range of components and get to making decision on subcomponents of the prior authorization, versus just in total. So it will take some doing to get there. We don’t think too many health plans have that level of rules sophistication to do all of this right off the bat.

Question: Our organization offers both government-sponsored products and commercial. The nursing shortage and clinical costs have really affected us greatly in staffing and spend. For our government-sponsored product, we can’t offshore clinical review. But for commercial product, we can. How can we address these issues?

Response: I think there are a couple of questions in that. Outsourcing has steadily increased over the past 8 to 10 years, and more and more commercial plans have offshored in that time. But we are also seeing in the past 3 to 4 years that many Medicare Advantage plans have also taken to outsourcing, particularly offshoring. Especially because of the recent nursing shortage—that demand has grown significantly. Where we do see hesitation is in the state-sponsored or Medicare-managed Medicaid plan, especially because there are two parts to that restriction—one is coming from their commitment to leveraging their in-state resources, but also finding the right nursing licensure offshore can be sometimes challenging. So in those cases, there are a couple of different options. The first thing is having automation built in for some of the clinical reviews. That is actually very beneficial with resource optimization. A clinical decisioning engine takes the burden off what falls into a clinician’s bucket. And then there are other creative ways to leverage some of the global talent in that you could decouple the process and have an onshore licensed clinician do an audit and 100% of the cases and release. There are other creative ways, as well, but I would say technology and having a tier one and tier two automation process would be the first pass at that.

Question: Like all government-sponsored plans we did not prior authorize services during Covid-19 and had reinstituted the prior authorization requirement in January 2023. For nearly a year now, we have been really struggling with both SLAs and a significant increase in volume of cases to handle. Can you offer three things we need to do to improve our operations?

Response: A full UM program really starts by looking at what are the trends driving the volume. Historically, I think plans have used a catch-all mechanism for prior authorization. But hopefully in this webinar we looked at UM as more than just managing volume. So how do we comprehensively look across the trends and use provider behaviors—look at network case rate optimization, etc—to become a full program? That way you aren’t just looking at the volume increase, you are looking at the trends in cost of care. I would say that would be one way to look at it. Again, using automation is one way to address the volume directly. So if you can automate some of the high-volume cases with clinical criteria that can support at least 60 to 70% of that process, there is management capability that comes from there. I would say auto approving those procedures that are not yielding high value helps keep an eye on trend without putting high cost to manage volume. So that is probably one way to look at managing the post-Covid volume.
It’s really analysis, analysis, analysis, from an ROI standpoint. From an operational perspective, look at how many you take in and is there any way to reduce the denominator, so you request less of them? And keep the subset so there is more opportunity of improving outcomes and think about it more from the clinical standpoint than you have in the past. Understand by category where you have more clinical impact than less, and base where less clinical value and more clinical value.

To view the replay of this compelling webinar, go to : https://sagilityhealth.com/post-ahip-webinar/

Visit www.Sagilityhealth.com to learn more.

BPO, supercharged: business process as a service drives scale, savings while exponentially enhancing outcomes

By Srikanth Lakshminarayanan, , Senior Vice President, Center of Excellence for Healthcare Engagement Services; Umesh Chandorkar, Vice President of Solutions for Sagility’s payer segment;  and Nikki Henck, Senior Director, Utilization Management

Health plans have long understood the benefits of business process outsourcing (BPO). Faced with the heightened prioritization of customer needs, experience, and value stream impact, these health organizations are now looking to drive more positive business outcomes through service providers on an “As a Service” model rather than the traditional transactional models.

Simply defined as the delivery of Business Process “As a Service,” (BPaaS) supercharges benefits — with end-to-end advantages from breakthrough cost savings and predictability of spend to enhanced competencies focus, risk management, and access to new technologies. 

Health plans are well suited to taking the benefits of BPaaS solutions spanning:

• With the pay-as-you-go model, organizations can better scale and align with needs as the business changes. This is additionally bolstered by metered tech investment and reduction, with system, platform, and solution costs assigned to the “As a Service provider.” BPaaS provides assured tech currency, data security, and scalability — reducing tech investment risk. With this shift from technology and operations spending “As a Service” enables health plans to accelerate growth with a core focus on product development.
• BPaaS helps centralize siloed operations for consistency across all units and improved process flows and outcomes. The BPaaS partner is uniquely incentivized to drive performance and optimize the resources and service levels—regardless of volume fluctuations.
• Professionally operated, auditable “As a Service enables stringent compliance that addresses the nuances of regulations and how they can affect business from an end-to-end perspective. These “As a Service” models also provide a lot of efficiency due to the experience BPO organizations bring, which is a core differentiator.

In The Front Office

Exceptional member experience is more important than ever, as supported by a modernized contact center and measured by value-based benchmarks. This experience is integral both for differentiating healthcare organizations and for preventing the loss of valuable customers. Contact Center As a Service (CCaaS) — essentially, the front door of “As a Service” —provides:

• An optimized consumer or member journey: CCaaS end-to-end journey mapping drives an enhanced experience. These member journeys can be enhanced using the CCaaS model, where all customer touchpoints are integrated, reducing the customer effort for the member.

• Plug-and-play experience optimization: The CCaaS solution suite comprises a fully integrated, cloud-based platform with bolt-on digital accelerators, including chat and chatbots, text, and speech and data analytics. AI-based omnichannel provides seamless resolution over multiple touchpoints and channels. In addition to channel preference customization, the results are improved efficiencies and a higher rate of touchpoint resolutions for the customer. 
• Up to 30%  cost savings in tech investment alone: With vendor accountability for bringing forward more robust, latest-and-greatest technology, health plans can also rely on additional predictability of spend and reduce their capital expenditure.

In The Back Office

In the back office, BPaaS delivers critical benefits—reducing administrative burden with access to modern tech and reducing the legacy burden and overall spend, with enhanced speed to market. BPaaS provides seamless integration with artificial intelligence (AI) and machine learning (ML) boosting benefits between claims, provider network operations, and pre-payment integrity checks. In these critical areas, BPaaS delivers:

• BPaaS seamless integration starts with claims intake, FWA rules, and auto adjudication rules. The result is the delivery of a streamlined processing environment, leading to more lean and efficient operations with significant cost savings. This includes interoperability between internal and external departments. Additionally, there is one-stop accountability from a compliance standpoint.

• Value-added robust analytics processing leverages the latest AI and ML tech, driving precision in payment accuracy and elimination of claims leakage.
• Accurate data management and timely payment ensures that provider and member abrasion is minimized – with quality provider data — and faster speed to pay.

Clinical

With the regulatory landscape and high cost of operation, health plans are critically evaluating their Utilization Management (UM) strategy and performance.  These organizations must focus on high-efficiency, end-to-end workflows that eliminate silos and bottlenecks in critical areas of health service management.  

• Real-time determinations and faster case turnarounds can reduce up to 40% of operating costs. This can be achieved by leveraging AI-enabled technology like automation, natural language processing, ML, and assistive technology. A well-connected UM workflow bridges critical touchpoints across operations and compliance with seamless service delivery – from intake to clinical and post-service review. One key use case is the high cost of manual prior authorizations — a fulcrum point where faxes and phone calls are inherent processes from which inaccuracies and inefficiencies result in delayed care and provider dissatisfaction. 
• Improved provider satisfaction can lead to higher NPS scores and Star ratings and better member engagement. Access to multi-channel prior authorization submission processes makes it easy for physician practices to submit prior authorizations over their preferred process at a time that is convenient, minimizing provider abrasion. The ability to obtain real-time decisions makes a world of difference to providers, as they ensure their patients get timely care — ultimately boosting member satisfaction, resulting in higher net promoter scores (NPS) and Star ratings. 
• Evidence-based care guidelines support appropriate ordering that is clinically indicated, thus ensuring patients get the right care. UM as a Service leverages evidence-based guidelines that support clinically indicated health services, resulting in better care quality, safety and cost savings, with a first-time-right process and more precise clinical decisioning. 
• The right BPaaS partner brings healthcare domain expertise that bridges gaps across these three areas of Front-Office, Back-Office, and Clinical. Additionally, a considerable advantage will be found with a partner that has end-to-end understandings and capabilities across the entire payer-provider ecosystem.

Article originally published in Healthcare Business Today.
Click here to read the full article

Facing both revenue and expense issues and exasperated by clinician shortages, hospitals are increasingly noting denials in the danger zone.  “Danger zone” translation: Denials are increasingly higher than 10%, costing significant dollars in lost or delayed reimbursements—as well as more overhead for rework and resubmitting claims. A recent Crowe RCA benchmarking analysis provided the industry-wide numbers: Claims denials rose to 11% of all claims last year, up nearly 8% from 2021. 

Winning with denials means focus on both administrative and clinical denials. On an average, clinical denials account for 45-50% of the total denials.  Not included in this number are payer post-pay audit payment takebacks.  Payers get a second chance at these denials, often two and three years post payment, but there is no second chance for a provider once service is rendered.  

Across both denials types, many outside experts bring a good mix of experience and capabilities across four critical areas of denials overturn: root-cause analysis, audits, analytics, and the right resources.

Root-cause analysis
Today, data on denials by every way it can be sliced—payer, revenue source, type—are available or can be built with limited investments.  Revenue cycle management (RCM) issues and inefficiencies have many root causes, and it is critical to track these to avoid revenue loss.  A stringent review of root cause analytics shows that the major sources of revenue savings are:

• It’s key to fix staffing shortages in critical areas of system and process integration.  Pressure on provider revenue cycle and other administrative teams to reduce costs, like labor, across all non-clinical areas of work have led to key controls and critical resources being let go. The experts, typically the middle management or consultants, required to bring together payer knowledge, clinicians, process, and technology are not available or have competing priorities.
• Implementing AI solutions to monitor service quality and coding will help keep pace with the increased AL based scrutiny by payers.
• There is a need for accelerated monitoring medical necessity requirements of payers, brought about due to the change in forms of reimbursement such as telehealth, remote monitoring, implants, and mainstream adoption of experimental procedures.

Audits
Successful auditing includes a strong foundation of clinical SMEs and a robust audit sampling solution, such as querying the 835 denial reasons against medical records and appeal letters. This will result in detailed focused audit samples that enable robust coaching and feedback mechanisms to the nurses that are preparing the appeal letters. Additionally, quarterly clinical quality rounds and reviews by MDs and specialists will facilitate accurate documentation of clinical criteria that reflect medical necessity in the appeal letters.
A scalable and holistic denial management approach keeps the patient in the center of the denial and looks for relevant and accurate information across consultants and episodes of care.

Similar to clinical audits, periodic reviews of the each non-clinical step involved in overturning a denials is essential.  Perhaps not the entire process but several processes controls can be automated.  Untimely filing write offs can be limited if worklists are automated based on appeal filing limits.  Often this information can also be used by contracting.  Some payers have a 30-day filing limit but a three-year timeline on payer post payment audits. Data on denial reversals, lag times, and medium of claim submissions can be made readily available based off information on PA systems. 

Analytics
Once there is clear understanding of the predictive nature of the denial trends, common findings can be applied into a predictable matrix based on historical trends. Then, AI-led querying of unstructured data and robust statistical methodology will allow propensity models to be deployed for managing efficient operations.
Also critical are payer processing rules, whether Milliman or Interqual, LCDs or NCDs and integrating automated controls. While case complexities impact the effectiveness of controls, providers continue to write off large amounts for authorization and medical necessity on recurring and other therapy services.  For example, it is possible for an automated control to be developed reminding a registrar that Ocrevus needs to be re-authorized or analytics to highlight non-typical variations in service coding from one month to another that could potentially impact payment.

The right resources
The cost of managing clinical denials operations is constrained due to the high cost of recruiting high-demand nurses and clinical teams. Highly cost-effective operations, without compromising on quality, leverage decoupling of the workflow between offshore clinicians and onshore SMEs and specialists.
With a routinized governance process with review of clinical acumen across specialties, supported by audits, multi-shore teams will achieve significant learning curve optimization. With conducting of Inter-rater reliability tests between the onshore and offshore teams, there is consistency in the quality of the appeal letters and establishing medical necessity.

The industry trend has been to skinny down on non-clinician staffing to control cost.  But successful denials overturn, ultimately, means finding the right Denials Team balance of clinical support and revenue cycle expertise. Often a clinician’s time is spent filing in appeal forms and uploading documents on portals—tasks that a non-clinician can perform and/or can be automated should be routed to non-clinical staff.   A revenue cycle management team that integrates the clinician, patient and payer, irrespective of location, is typically the most effective.

TRANSFORMATIVE AI TO REVAMP PRIOR AUTHORIZATIONS

Tech enablement drives lower costs, lessened provider abrasion

Health plans are unnecessarily burdened by administrative tasks such as prior authorization—a costly bottleneck to optimized care and operational outcomes. Recent American Hospital Association (AHA) research states that that 95% of providers spend increasing time seeking prior authorization approval. An astounding 78% of hospitals and health systems said their relationship with commercial insurers is getting worse. What’s needed is relief at this high-impact payer-provider touchpoint. AI-enabled prior authorizations can help. According to McKinsey analysis, AI-enabled prior authorizations can automate up to 75% of manual tasks. This tech enablement solves for many of the inefficiencies while working to improve payer and provider synergy, reduce costs, improve case turnaround time, and, most importantly, drive better health outcomes for patients.

Drivers to Digital Utilization Management

The case has never been clearer for a straightforward, faster, and impactful PA process. High-impact PA ups the ante with an analytical approach to flag clinical decisions that need priority nurse review. The algorithmic decision support can identify high dollar clinical usage patterns, FWA patterns and CPT conversion/alternative treatment. Traditional, siloed UM programs are not adequate to meet current market conditions: a high-cost clinical resource pool and financially pressured payers and providers. Add to that this simple fact: our internal research shows that 80+% of authorizations reviewed are eventually approved without any modifications, and only a few of the cases need a detailed review for necessity. This leaves a lot of room for digital intervention in the provider interaction channel to instantly auto-approve and provide an outcome via digital assists for better member care.

Experts such as healthcare business process management partners have the combined digital solution and skillset: experienced clinicians supported by AI workflows to effectively manage the process and cost. Backed by process re-engineering, automation and digitization of the prior authorization process will ease provider burnout and change the perception of this process. Traditionally, the prior authorization step has been viewed as cumbersome, with high administrative costs running into billions of dollars across the US healthcare sector. BPM partners with experience across both payers and providers can collaborate and bridge gaps to improve the overall ecosystem of population health and give a better dollar accountability and visibility. As a result, transformed, high-value utilization reviews will drive to lower-cost per review using state specific/CMS guidelines and a 99%+ calibration with medical directors on review decisions.

UM Augmented with Transformation Levers

The front- and back-office digital suite of solutions use automated speech recognition (ASR), NLP of medical entities, contextual insights, computer vision, and machine learning feedback to evaluate prior authorization requests against automated guideline rules. The outcomes are provided via digital nurses on some channels and nurse assist flows on others, each with comprehensive criteria summary and recommendation on approval or referral to a medical director.

Outcomes and Future of Clinical Reviews

BPM partners with experienced clinical resources combined with AI workflows can manage the PA process cost effectively and find transformation with process effectiveness. For the first launch of the back-office solution for a top payer client, Sagility’s prior authorization medical record review automation leveraged in-house asset Intelligent Content Processing (ICP) for a 20% efficiency gain across the entire document review process, with a line item gain of 75% error reduction, in some cases. With the buildup of this platform to transform clinical data into intelligence to reduce process complexity, enhance accuracy, and speed TAT which is 7-10 minutes saved per case transaction. Through machine learning, these savings will compound over time, for up to 40% cost savings for identified scenarios. This powerful tool will also drive significant TAT improvements as well as enriched provider and member experience (potential Star and NPS ratings impact) from improvements on quality with reduction in nurse error and nurse glide path, enhanced productivity, decrease in regional medical director (RMD) routes, increase in identification of potential approvals for nurse to review and also decrease in number of cases referred to physician.

Transforming the front office with the voice assist and context bots results in auto-approvals for high volume procedures. This directly reduces call volume reduction by 10-15%. The next-best action and access to unified knowledge bases have driven a shortening of complex prior authorization calls, for 15-20% savings via handle time reduction. The continuous digital bot and agent monitoring metrics have also resulted in an internal training glide path reduction by 50%, ensuring the quality of outcome at above 99%+. Overall savings in the front office can be at least 20% as skilled resources need no longer work on administrative tasks anymore.

As next steps, any outcomes of clinical decision support that sources from a unified data lake of claims, medical records, and member profiles can be successfully linked with population health outcomes and patient profile stratification. This will result in insights on high risk population analysis, population trends and wellness management, and, finally, risk scoring of individuals and proactive population management. Weaving in provider profiles can also help provide in extension insights on the segmentation, scorecards, and comparative analytics to evaluate provider utilization and abuse, if any.

Three healthcare cloud myths, debunked

With ever-increasing, rigid regulations, and the most sensitive personal data of any industry, healthcare has walked slowly toward technology and transformation. And this is particularly true when it comes to the cloud. COVID-19 may have been the catalyst in forcing healthcare’s hand, with the industry required to quickly implement employee work from home, patient/member self-service and online engagement, and telemedicine solutions.

According to recent research, nearly 70% of healthcare leaders expect to move their technology infrastructures to the cloud this year – a number that is set to rise to 96% by 2024. Today you won’t find many healthcare organizations without a cloud strategy—and that often means partnering with BPOs. These experts have the right technology, tools, training, and processes to launch a Contact Center as a Service (CCaaS), otherwise known as a cloud-based customer experience solution. Deploy-on-demand CCaaS platforms provide full suite or a la carte capabilities and options, making it quick and easy for healthcare organizations of all sizes to personalize and optimize customer experiences.

Here we dispel some common myths about healthcare cloud—and CCaaS, in particular.

• MYTH: Healthcare CCaaS is expensive.
  • FACT: CCaaS has proven to optimize operations for any size healthcare organization—whether large or small. Expensive legacy on-premise solutions often come with complex pricing and large upfront costs. Increasingly, CCaaS is subscription based or pay-as-you-go. Also, CCaaS allows for healthcare’s seasonality and sizing up for peaks and open enrollment. Additionally, CCaaS is proven to be resilient, with avoidance of painful, frequent outages that cause lapses in service, lost revenue, wasted agent labor, and excessive troubleshooting. With multiple redundancies built in, there is a failover system in place. Finally, the savings of CCaaS are significant. In fact, the industry has observed 30% client savings with leveraging of CCaaS.
• MYTH: The cloud compromises healthcare organizations’ data and information.
  • FACT: With more security capabilities built into the software stack available to deploy by experts, security is increasingly cited as a benefit of CCaaS. CCaaS reduces dependency on local hardware for storage of sensitive data, with automated software updates to keep systems and security certificates current.

• MYTH: CCaaS is difficult for organizations to adopt.
  • FACT: Compared to implementing a customized, on-prem call center solution, the CCaaS is turnkey and easy to deploy. And integrating with a healthcare organization’s systems and data is no more difficult than on-prem. With CCaaS, organizations have reduced dependency on one-off custom implementations over-reliant on key individuals. With deployment of CCaaS by BPO experts, you have a resilient, focused workforce.

The healthcare BPOs that can best optimize CCaaS opportunities help drive outcomes like:

• Dynamic, personalized, and natural automated experiences for member and provider interactions thereby being a NPS/CSAT driver.
• Up to 30% cost savings on total cost of ownership across CAPEX and OPEX.
• One AI- and ML-powered platform for workflows, agent management and interactions, routing, and experiences across omnichannel and self-serve for the organization.
• Reduced call volume by up to 10%.
• Reduced supervisor effort by up to 20%.
• Shortened AHT by up to 15%.
• Reduced training time by at least one week.
• Reduced license and usage costs by 30%.

Modernized, AI-enabled VoC to Meet Today’s Healthcare interactions

Today’s healthcare members will act on failure to meet their expectations, according to recent Forrester research, with 34% of dissatisfied customers changing health plans. Equipped with this knowledge, health insurance plans can renew their focus on measurement of Voice of the Customer survey feedback to improve customer engagement, loyalty and retention. But a truly effective and statistically significant VoC solution requires not only user-centric (design thinking) questions, tools, and technology—what’s also needed is the right volume and rich quality of data backed by NLP/AI interaction mining platform. Working together, the solutions and data can deliver meaningful and actionable insights to drive positive business outcomes. An Analytics CoE can serve as nerve center of healthcare interactions, using the following frameworks:

• Journey mapping, measurement, and ownership (customer effort, sentiments, emotion analytics)
• Insights-driven experience and process improvements to ease customer friction points by contact types, and reduce agent effort reduction by providing tools, with an increased engagement rate
• Leveraging of technology to meet stated and unstated customer needs and experiences

Increasingly, the healthcare VoC survey is embraced as an essential driver of member/patient satisfaction and retention. In fact, Gartner forecasts that by 2025, 60% of organizations with VoC programs will supplement traditional surveys by analyzing real-time or near real-time voice and text interactions at every customer touchpoint.

Today’s optimized and AI-enabled VoC survey will meet the mark for improved member experience in two key areas across both commercial and Medicare member bases:

• Commercial
  • Self-service channel friction: A section of healthcare customers expecting an Amazon-like experience will not get it when self-service engagement is not optimized. The right VoC survey will address this with questions that get to the heart of self-service misses with good failure modes and effects analysis (FMEA). Once self-service complexities with simple contact types are discovered, they can be addressed with fixes for a more seamless customer journey. Examples include fulfilment and eligibility contact types (Member ID cards, demographic updates and the routine office visit copay)
  • Contact deflection: On the opposite end of the complex calls are the simpler contacts that can be deflected with proactive digital solutions such as service automation. Deployment of post-call IVR voice of customer with NLP/AI enabled survey verbatim/sentiment mining will improve operational engagement, agent coaching opportunities and experience metrics. And once identified, a good deflection and prevention strategy can digitize the contact solution for millions in savings.  Examples include billing (Monthly Premium payment related contact type)
• Medicare
  • Unresolved issues resulting in repeat contacts and complaint tracking module (CTM) issues: This is a crucial journey point to check in on with the Medicare member VoC survey. When plans discover root causes of CTM, unresolved issues can be addressed not just for one payer but for a wide demographic—for greater ROI and improvement. Without a team to reach out to a member at this escalation point, you aren’t closing the loop on those issues that cause a member to change health plans. With technology, process, and people in place to address survey-discovered escalations, the long-term gain is significant.
  • Call types that trend toward a higher propensity to appeals: Post-call VoCs can baseline and benchmark closure or the people/process/policy/tech gaps that drive appeals. Sagility has leveraged, for two leading payers with MAPD plans, our VoC solution in areas of transportation/ambulance, late enrollment penalty premium and policy disenrollment/reinstatement. Once value stream mapping is done and upstream/downstream mapping is conducted, pertinent solutions/resolutions are deployed at the upstream (customer service) area to reduce unnecessary downstream appeals.

In these areas and more, AI-empowered healthcare VoC can optimize survey distribution, feedback, and issue root cause analysis. We helped a leading payer to achieve results addressing these common weaknesses, delivering value empowered by automation. This tech enablement has helped expand VoC feedback from 1,000 surveys a year to 1,000 surveys a day. We also redesigned the survey, reducing it from 18 questions to 5, which reduced survey time from 10 minutes to 1 minute. Additional results included:

• Improved Survey to Call Ratio 0.16% to 9%
• Increased FCR by 26% (59-85%)
• Increased ASAT by 22% (71% to 94%)
• Reduced manual survey administration, achieving cost avoidance by $2 million

These results demonstrate how survey experts can drive to more impactful and much broader feedback, for the true impact and consultative value delivered by healthcare BPOs. These specialty BPOs in are experts with the required skills across tech, process, and teams of experts to make business process improvement recommendations with a VoC champion. With a solid structure in place to support an enhanced VoC survey process, ROI is heightened.  Today’s robust VoC framework builds in feedback that can drive real outcomes when addressing process, product, and engagement channel improvement opportunities.

The digital age has shed new light on the need for interoperability for healthcare, as backed by recent imperatives such as the Centers for Medicare & Medicaid Services (CMS) Fast Healthcare Interoperability Resources (FHIR) or the Provider Gold Card standards. These regulations can drive quicker adoption and usher in new approaches for today’s healthcare organizations. Both payers and providers are now turning to these disrupters to check table stakes efficiencies off the list: from proactively improving accuracy and turnaround time of claims data to tracking member and patient interactions to build intelligence for future impact. But in the line-up of technology superpowers, back-office technology is an often unsung hero. As a goldmine of claims-related and member and provider data, back-office transformation is increasingly delivering significant cost savings through the use of intelligent service and technology innovations, with an often less complex implementation. In the back-office—a fulcrum of claims-related and member and provider data—these accelerators are key:

1. Process Mining:

These tools rapidly understand workflow nuances and begin solution development very quickly and with minimal interruption to business processes. By translating the subjective model to an objective one, this mining is a measurable study in the process discovery itself. Process mining initiatives aim to collect insights and intelligence for reimagining the payer-provider operations and develop deeper insights from the process to measure the efficacy, efficiency, and continuous improvement to enable data driven decisions. Process mining can also be the bridge that enables transformational solutions to cut across payer-provider front-office and back-office areas by yielding opportunities to streamline processes to their most optimum form. The combination of a zero-day approach to consulting and process mining will quickly unlock value for payers and providers. This would be the first step in design of enhanced workflow, as part of discovery.

2. Intelligent Automation (IA):

As a combination of RPA (Robotic Process Automation) and AI (Artificial Intelligence), IA allows for automation of routine steps that are rule based and repetitive, accessing one or more steps or volume driven. Salient features of IA include:

• Non-invasive technology
• Technologically agnostic solution
• Seamless use of existing end-user interfaces and enterprise applications
• Ability to use software robots to log into systems, function with security controls, and restrict access rights
• Ability to analyze structured, semi-structured and unstructured data sources and convert into insights

IA can be effectively leveraged as a transformation lever across the entire claims lifecycle for payers and the revenue cycle journey for providers. An example of IA in action would be a large managed health care payer benefitting from 50% efficiency gains in addition to claim error reduction from intelligent automation bots being created to validate member, provider, billing and coding information as a part of the claims processing in the claims lifecycle.

2. Intelligent Content Processing (ICP):

ICP transforms unstructured and semi-structured information into usable data. Rather than leveraging a single technology as is the case with optical character recognition (OCR), ICP uses a suite of AI technologies including machine learning (ML), natural language processing (NLP), Computer Vision and deep learning to classify, categorize and extract relevant information, and validate the extracted data. This extracted content is formatted to enable downstream processes toutilize it as per the requirements. An embedded ML model, within ICP, can identify the type of document and extract content irrespective of the template of the document. Sagility has deployed ICP in delivery processes across healthcare payers and providers. Some common use-cases are in processing medical records for medical/utilization management, processing appeals and grievances, performing payment integrity audits and KFI activities.

3. Web context channel:

A web-based contact channel works much like a digital voice assistant except that the conversational AI here is comprised of via textual inputs delivered via a web / mobile / progressive application portal. A member or provider will interact with input forms or an NLP-based contextual chat to complete a questionnaire. As a mix of a deterministic and probabilistic model, interactions are sourced from the unified truth, or knowledge base, that has been continually learning and growing over time.

In addition to prior authorization, digital agents via voice and text can also address queries across member eligibility, explanation of benefits and claim status. There is also high applicability in the DME space, where supply chain-related queries pertaining to order status, inquiry, payments, and dispatch can be entirely digital-agent driven.

4. Intelligent Agent Guidance (IAG):

On top of automation and ICP, IAG gives the agent the logical next step—prescriptive analytics to save from an error in workflow to guide workflow and more quickly assist with turnaround work.For processes not a part of unattended RPA processing, intelligent guidance technology can be an excellent way to create a superior agent experience as they cooperate with bots. Intelligent Guidance technology as a layer over payer and provider applications, is an easy to follow, contextual, step-by-step process within existing provider and payer applications that will reduce agent stress levels, andreduce training time while improvingdata processing quality. The guidance appears on screen in real time to guide the agent through each step of the process in question.High-level benefits of a strong digital adoption layer include a user and process-centric approach to enhance onboarding and training.

5. Analytics and Insights:

Good back-office strategy means generating actionable insights through data analytics to help improve the delivery of back-office services and payer-provider experience. Analytics is performed on various data sets to understand the trends and patterns relevant to payer and provider business. From operational metric analytics to agent quality analytics, from post facto to predictive analytics – an integrated approach to analytics helps generate immense value for our clients on ongoing basis. Typical use-cases across payer /provider journeys include population profiler for care management, smart audits of claims, over payments identification and financial recovery forecasting. MIS, reporting, and dashboards are also integral with design of key interfaces to provide near real-time reports to clients.Prior authorizations are a good example of a unified truth source where analytics can help with provider stratification or gold carding, to indicate providers aligned to efficient authorizations and process.

For healthcare payers and providers alike, a digital-first strategy leans on these back-office accelerators for:

• 10-20% savings via operational insights generated by predictive and business intelligence services offered across healthcare payer services
• 20-30% savings in intelligent document processing across payment integrity, appeals and grievances, and key for information
• 25-40% cost savings to key clients through intelligentautomation and process reengineering.

Together, these disrupters seize many opportunities—as a center for payer-provider collaboration and an improved journey for members/patients.

Bridging journey gaps through the digital front door

In terms of optimized healthcare experience delivery, the digital front door has been less an entry point and more an essential touchpoint of the complete healthcare member journey that connects experience and care. While health insurance has been flagged for low customer satisfaction in the past, that’s all changing with new digital levers that bridge journey gaps.

These transformation levers are leaning on customized healthcare domain and journey-specific contextual information to drive significant boosts in member / provider engagement, satisfaction, and brand loyalty. The key focus is to empower members / providers to self-serve based on their channel or medium of choice for a faster response.

One core disrupter has been the digital front office leveraging a knowledge base of unified truth across member, provider, and claims data. When framing and enveloping a seamless experience across every step of the customer journey, three accelerators are increasingly critical: voice contact flow, web context channel, and the ultra agent.

1. Voice contact flow:

Evolving tools can address different fluency levels by leaning on a robust knowledge base boost. When supported by intelligent AI-powered IVR, automated speech recognition (ASR) and natural language processing (NLP) can more efficiently address member and provider queries. This HIPAA-compliant integration leverages business and algorithmic edits for suggestion of next-best actions for decision making. With automation built on top of business rules and contextual inferences from interactions, IVR integration is optimized with experience, cognitive learning, and an evolving knowledge base.

One case example would be prior authorization approvals in real time — for example, a digital nurse providing required approvals via voice for the procedure type in question. The auto-approval process is reinforced via feedback from an approval propensity model which draws from the unified truth. Based on the voice-driven contact flow, if the auto-approval process is incomplete or needs more evidence, it will be routed to an ultra agent for closure.

2. Web context channel:

A web-based contact channel works much like a digital voice assistant except that the conversational AI here is comprised of via textual inputs delivered via a web / mobile / progressive application portal. A member or provider will interact with input forms or an NLP-based contextual chat to complete a questionnaire. As a mix of a deterministic and probabilistic model, interactions are sourced from the unified truth, or knowledge base, that has been continually learning and growing over time.

In addition to prior authorization, digital agents via voice and text can also address queries across member eligibility, explanation of benefits and claim status. There is also high applicability in the DME space, where supply chain-related queries pertaining to order status, inquiry, payments, and dispatch can be entirely digital-agent driven.

3. Ultra agent:

With introduction of these solutions and the foundation of a machine learning (ML)-powered knowledge base — involvement of the agent will be more exception based. When an ultra agent is introduced for escalation, tech-agent ingenuity better addresses any complexities. The ultra agent is super powered and armed with more accurate and timely information with a unified desktop for next-best actions supported by comprehensive case history, interaction disposition, AI-powered suggestions, and the unified knowledge truth. All of this comes in the form of digital tools that help with timely assimilation of the required information and optimized interaction with member experience focus.

Working in tandem across interaction channels, these three accelerators are delivering:

• Contact volume reductions of 15-20%
• Call handle time reductions of 15-20%
• Reduced provider and member abrasion
• Enhanced provider and member satisfaction with NPS®, CSAT, and Star ratings boosts
• Aggregate cost savings of up to 30-35%, including administrative costs

A well-traveled journey starts with a good map and guideposts. Ultimately, these digital-first front-office accelerators help meet member / provider demand for a concierge, frictionless, and fast experience. For healthcare organizations, a digital-first strategy leverages these accelerators to drive to positive impact across care experience, costs, and outcomes.

The past two years have brought a perfect storm of challenges for healthcare providers. COVID-19 has had a profound impact on healthcare overall—resulting in one of the all-time worst financial crises for providers. And the talent supply and demand gap has only widened as a result of compounding factors like the Great Resignation, the remote work shift, and workforce competition with employers crossing state lines to resource affordable talent. As a result, today’s healthcare providers are seeking transformation at the core of the challenge: attracting and retaining customer contact center provider services and revenue cycle talent.

Kaufman Hall surveyed hospital and health system leaders and learned that 75% of these leaders said their organization has experienced adverse revenue cycle impacts during the pandemic. And 92% of leaders said their organization is challenged with attracting and retaining support staff.

With high staff turnover due to vaccine mandates, employee burnout, and other new normal challenges, there is a pressing need for not just qualified resources—but the required supporting operational excellence and innovation needed to successfully execute on within new operating models. Today’s smart healthcare business process management (BPM) partners are among the best equipped to assist healthcare providers in accomplishing how to effectively address talent new challenges—with well-refined workforce management agility strategies to recruit, hire, and train the right talent across multiple geographies.

Today’s leading BPMs bring the healthcare operational best practices and astute skills to enable healthcare providers to compete more effectively under the current and evolving market conditions. Here we highlight three critical areas where the right BPM partner can help healthcare providers win the competition for talent:

1. Optimized virtual recruitment with tech-enabled, right-fit profiling:

With delivery centers strategically placed to align with unique provider staffing and labor cost requirements, and proven work-at-home programs, BPMs also have developed refined processes to recruit in the post-pandemic reality.

Well-experienced healthcare BPMs bring the flexibility to adjust to the changing needs of clients to right-size staff to meet volume fluctuations. These BPMs can often offer multiple delivery location options onshore, nearshore, or offshore, as well as blended shore options to optimize staff availability and specific process expertise.

To align with current remote-working solutions, some BPMs have developed the requisite artificial intelligence (AI) and machine learning tools to perform role-based assessments to assist with finding the most qualified resources, while as well leveraging live video technologies to conduct interviews for successful hiring. These partners can incorporate virtual onboarding used with an integrated system and structured hiring process, regardless of geography.

Sagility case example:

Achieving a highly qualified hire is a top-of-mind item for every organization. Adding in remote hiring, video interviews, and remote assessments only creates greater risk of bad hires. In our experience of running captive healthcare payer operations, personnel is always a priority. The BPM industry has always provided a solution to staffing challenges, and Sagility is no exception.

At Sagility, all aspects of the employee lifecycle are conducted virtually and handheld by our cultural ambassadors for immediate connection to the organization. Our hiring strategy is supported by industry experts who create profile-matching, strong geography-hiring strategy, and realistic job previews. We have adapted to create a complete technological application that is built around AI learning, self-service, and real-time recruiter attention. This is all front-ended by our house-built bot application, which yields prepared, on-time hires.

2. Strong work-at-home solutions with improved quality and reduced attrition:

During the COVID-19 pandemic, the healthcare industry was required to quickly implement work-at-home solutions. There was a new appreciation for the value of offsite employees, with BPM partners already accustomed to secure work-at-home implementations.

Due to the lack of experience and limited understanding of these new approaches, some healthcare providers have been turning to the right BPM with a well-refined work-at-home program, including compliant technologies, standard operating procedures, remote processes, infrastructure, and training programs ready to deploy.

Ensuring strong program quality and resource retention means providing these remote employees the right tools for the job, while also providing the training and management structure needed to ensure successful job performance. BPMs have the expertise to quickly configure tools for secure access to necessary client systems while adhering to all compliance requirements. With the right technology, tools, training, and processes, the quality control and service-level adherence is achieved as a result of well-prepared employees.

Sagility case example:

Sagility has adapted to COVID-19 market changes to ensure work-at-home solutions are efficient and comfortable with speech analytics, an employee engagement reward system, and a complete remote performance dashboard and coaching platform. These integrations increase retention, maintain compliance, and ensure an always-ready workforce. Additionally, this strategy creates ease in the member experience. More importantly, we have increased our ability to right-fit candidates to our diverse profile of client needs. Year over year, our CSAT, NPS, and VOE results increase despite the current work conditions. Providing these types of tools for support and advocate use creates a more effective candidate and a better quality of care. Ultimately, Sagility strategies have often become enterprise-adopted practices, as the quality of service is unmatched.

3. Better satisfaction scores for clients, customers, and employees:

Winning the talent competition means harnessing the power of engaged, inspired employees. Engaged and inspired employees translate to better results.

Sagility prioritizes maintaining employee engagement and mental wellness in a virtual environment. Today’s BPMs encourage employee engagement activities, like gamification, during training sessions. Employee Assistance Programs (EAPs) and HR helplines are always at the ready to provide needed support.

Sagility case example:

COVID-19 has been a straining exercise on our community, family, and individual well-being. Additional stress includes an aggressive opening in remote opportunities, which has made interpersonal connectively a foreign concept. Sagility knows people are everything; we have a people-first mentality and create a structure that supports overall well-being.

Our mission is a motivated and dedicated employee who understands their individual contribution is larger than it seems. Internal campaigns around access to care, first contact resolution, and best outcome treatment keeps the staff grounded and focused. Our leadership focus is access to EAP, HR helplines, paid leave, future preparedness, and crisis help services. When people come first, the results for our clients are high CSAT, NPS, and Star ratings. This results in growth and success for all included.

Undoubtedly, the past two-plus years have tested even the strongest healthcare organizations. Hiring and retaining the best talent has never been more crucial to the financial health of healthcare providers. The right BPM can deliver strong and consistent results to achieve success with the winning talent required

Even pre-COVID-19, claims fraud, waste, and abuse (FWA) was a top-of-the-agenda issue for health plans aiming to evolve both care quality and consumer experience expectations. But the pandemic has surely raised the stakes for a need for a whole new payment integrity (PI) architecture, including complete process re-engineering and AI, automation, and analytics enablement. Health plans are grappling with compounding operational challenges — from aberrant services related to COVID-19 diagnoses to service shifts, uncontrolled telehealth expansion and, of course, labor shortages.

How can payers precisely address payment integrity needs while also strategizing healthy fiscal futures?

Here we provide three factors of the heightened PI pressures, with guidance on how PI solution experts can help.

1. Volume fluctuations and resource challenges

Complications affecting accurate forecasting of utilization and payments include excessive COVID-19 diagnosis, extended visit durations and increased visits for therapies, and early refills and disbursement of excess prescribed quantities for pharmacy and durable medical equipment (DME).

In addition to the existing legacy wastage and abuse issues within claims processes, there is now a greater need for specialized processes within payment integrity.

The return-to-normal volumes predicted for quarter three rested mostly on coronavirus utilization — with varying results across payers. There was COVID-19-related higher medical loss ratio increase for some payers — with some payers experiencing deferred care but often not at predicted levels. While other payers had higher than expected deferred care, there were also plans showing continued declines in enrollment.

The unpredictability across payments and bills resulted in operational challenges only heightened by the labor shortage. Health plans are challenged with multiple effects of this shortage — on top of enrollment declines, there are struggles with remote work, resource reallocation to support critical COVID-19 initiatives, and the resulting recruitment and retention of billing staff.

All of this amounts to operational disorder to effect more billing inaccuracies and payment errors. In addition to agility and flexing to meet seasonal shifts, another challenge lies in putting data to use to identify the aberrant providers, erroneous claims, and incorrect payments.

HOW PAYMENT INTEGRITY EXPERTS CAN HELP WITH VOLUMES AND RESOURCING:

Elevated people, process, and technology payment integrity expertise is needed to help design a program that will be able to handle these fluctuations and resource challenges allowing organizations to step up the audit accuracy focus — with rules and query writing for a prepay focus.

The right experts leverage a pre- to post-pay approach for a proactive and preventive strategy to exponentially drive down inaccuracies and overpayments for improved recoup for payers over time. These experts can provide top-notch analytics tools and techniques that are combined with automation, machine learning, custom configuration, and manual review and intervention to analyze the claims data. The right experts deliver a brain-bot combination as they also bring the human ingenuity via skilled, experienced payment integrity specialists. Finally, the right payment integrity expertise requires robust internal business analytics solutions that depend on knowledgeable resources across IT, PI, and the SIU to maximize actionable findings.

2. Expansive state and federal regulation changes coupled with demand for transparency

The pandemic has brought swift changes in regulations and policies to ensure access to patient care. Health plans have been burdened with more and more administrative lift as well as increased regulations focused on greater transparency in billing processes — beyond the already tall order for modern-day member care and experience focus. Now these plans have to keep in step with federal government regulations while also enforcing individual states’ mandates regarding “non-essential” claims processes and review of COVID-19 related claims.

Among the many pandemic payment fallouts, this scenario is played out daily — a patient with coronavirus symptoms undergoes not just the COVID-19 test but possibly other tests to rule out respiratory problems. Confusion around payment, services, and improper coding are just a few of the factors that can then result in a surprise bill. This bill starts a long and expensive journey to correct coding and payment — at a significant loss to all parties: patient, provider, and payer. This surprise bill is today a key focus of the NSA relating to how providers and payers will communicate with individuals on hospital billing of payers and will also make the reconciliation process more complicated.

Ultimately, new government regulation, COVID-19 requirements, exceptions, and payment-related complexities have only intensified payment integrity challenges.

HOW PAYMENT INTEGRITY EXPERTS CAN HELP KEEP PACE WITH REGULATION CHANGES:

These experts can provide the deep domain and current understanding of regulations and rules, augmented by the requisite highly trained claims and coding expertise to optimize operations for payers. Payment integrity solution providers also have the required stringent attention to drive improved accuracy of information between provider and payer to ensure that there isn’t a post-pay audit issue associated with the par/nonpar provider in relation to new regulations around billing processes.

3. Rapid increase of telehealth billing and inaccuracies

Early in the pandemic, telehealth utilization surged as consumers and providers sought ways to safely access and deliver healthcare. At the core of COVID-19 disruption are emerging services and new medical coding and billing procedures — with telehealth at the top of the list. A significant number of health plans expanded coverage for telemedicine and telehealth services related to behavioral health, specialist visits, and primary care so people could receive care while remaining safe at home.

In April 2020, research showed that overall telehealth utilization for office visits and outpatient care was 78 times higher than in February 2020.

In addition to the patient/member-centric benefits of access to providers, telehealth also brings potential coding and payment aberrations. Case in point, there is the risk of coding of e-visit or virtual check-in claims to higher-level telehealth visits, as well as up-coding of evaluation and management (E&M) services to a higher level of service than actually rendered. Undoubtedly, the addition of telehealth will surely drive an increase to stats like yesterday’s citation of 80% of medical bills with errors, per Medical Billing Advocates of America research.

HOW PAYMENT INTEGRITY EXPERTS CAN HELP WITH TELEHEALTH BILLING:

Health plans are experiencing a clear need for highly trained coding resources that can meet CMS timelines and unforeseen resource demand. The right payment integrity experts will bring rightshoring of cost-effective resources that are highly trained AHIMAs or AAPC-certified coders. This labor pool can further scale quickly and complete projects of any size with the maximum level of accuracy following a proven quality assurance process.

In conclusion

As expert problem solvers, payment integrity solution providers have the best exposure to the understanding of the nuances of the COVID-19 impact, including the regulations and how they can affect business from an end-to-end perspective.

The global reach of some of these service providers allows for rightshoring models that ensure that compliance standards are met while still providing cost and operational optimization, with the implementation of new tools, such as analytics, AI, and automation.

The healthcare industry presents a complex lifecycle of stakeholders with financial impacts and experience expectations — and payers must answer to all of them. These parties are all influencers of market position, image and, ultimately, success. With the right payment integrity approach and finely tuned focus, payers will find the exceptional service execution require to thrive in today’s environment.

Postponement of nonessential surgical procedures early in the coronavirus pandemic not only disrupted surgical care at U.S. hospitals, but also took away a large portion of hospitals’ total income, according to two recent studies. The University of Pennsylvania and Children’s Hospital of Philadelphia findings were presented at the virtual American College of Surgeons (ACS) Clinical Congress 2021. Nationwide, hospitals lost $1.53 billion from missed elective pediatric procedures alone, during the first three months of the pandemic — March to May in 2020. Thus, involvement of RCM BPO expertise is critical to fast-track revenue collections and enable providers to do what they do best: provide safe and effective care to patients.

Challenges in data science deployments

A machine-learning (ML) system is not just code; it is the combination of code, data, parameters, and training environment. Today, most healthcare organizations are looking at the potential of using AI/ML in helping achieving business outcomes and, despite significant investments, data science fails to make the desired impact. Key reasons include:

• Data science literacy at senior levels — Often, data science models do not survive the proof-of-concept (POC) stage, and they are sidelined due to a lack of fundamental data literacy at senior levels of the organization.
• Data findings conflict with intended course of action — At times, if data findings conflict with intended course of action usually derived based on past experience and gut feel, that could jeopardize the adoption of data science recommendations.
• Data availability, quality, and preparation issues — Collection of the required data is a challenging task. Data exists in both structured and unstructured format and is stored in various places with unique security and privacy issues. Data cleaning is a primary task before any form of analysis. Unstructured data or unformatted data, which may take most of the time for data cleaning, can be a reason for losing motivation. Insufficient data that is available for the analysis can also be a factor for failed AI/ML projects.
• Traditional RCM metrics are usually “lag indicators” — The primary KPIs by which practices measure revenue cycle performance are largely retrospective in nature: net collections, days in A/R, denial rates, and cost to collect, to name a few.
• Availability of skill-set — There is a profound lack of deep technical expertise and business acumen by data scientists in areas other than data science. You rarely find a data scientist who can take a step further to understand how a java backend application works and exchanges data. Strong business acumen (i.e., understanding of the provider RCM) is also critical to developing successful data science POCs.
• Analysis — Paralysis, challenges in building a compelling data story — There is a tendency to pick a large scope for deploying analytics and getting lost in the details. A lack of a clear data story telling leads to a vague explanation of analysis and recommendations. This delays / hampers the adoption of data culture in the organization.

Building a data culture

To arrive at the right business decisions, it’s critical that you start with the right business questions. Some pointers that could help build a successful data culture are as follows:

1. Investing in data literacy across the organization. Specialized training should be offered just in time.
2. Data-driven culture building. It starts at the very top. Include data in the decision-making process. Get in the habit of explaining analytical choices.
3. Fix basic data-access issues quickly.
4. Choose metrics with care. Move from retrospective to real-time reporting and action.
5. Build a data science center of excellence (CoE). Invest in building a team with deep business acumen and data science skill sets.
6. Make proofs of concept simple and robust, not fancy and brittle. Be willing to trade flexibility for consistency — at least in the short term.

Recent wins in data science deployments

Sagility has been able to build successful ML models to determine propensity of claim resolution and payments and optimize resolution efforts by identifying patterns of claims that could result in non-cash resolution. As a result of the deployment of Propensity-to-Pay Analytics Model, the Sagility team has delivered these breakthrough results for one leading national health system and longstanding client partner, for which Sagility manages multiple service lines, including Physician, Credit Balances, Payment Posting, and Day 1 A/R.

• Sagility helped the client save $.4 million, for a 15% increase in the cash collections on claims within 90 days from the date of placement.
• The client had benchmarked cash collections 0 – 90 days from the claim placement date at 25%. Sagility is now operating at 28.5%, which is well above the benchmark.

Looking ahead

The potential for big data analytics / data science is huge in the future. Machine learning can also process the information much faster with its accelerated learning and advanced capabilities. Based on this, the time required for solving complex problems is significantly reduced. However, data is most useful when everyone has the ability to explore it, both individually and collaboratively, with other team members. The democratization of data and collaborative analytics are the future of business intelligence.

Over the past 18 months, healthcare providers have grappled with historic cost and care challenges. The COVID-19 pandemic has increasingly forced providers to assess new areas of transformation to unlock operational value and cost efficiencies. Unique trials call for alternative solutions, and health systems are taking a new look at cost and process-challenged areas like coding, which has been an area often operationally underestimated and rife with misconceptions. Here we dispel some common myths by presenting facts about how effective coding can not only help providers survive the current market but start thriving with proactive denials prevention and insights.

1. MYTH: There is no labor shortage..

FACT: There is a labor shortage of skilled coding specialists. Especially in light of the pandemic, businesses across industries are facing critical labor challenges. According to the Bureau of Labor Statistics, since February 2020, as the pandemic took hold in the United States, healthcare employment is down by 542,000 positions. And even before the pandemic, the BLS predicted a surging need for coders, with job growth of 15%. This supply-and-demand scenario is bolstered by the rise of telemedicine, new codes, multiple guideline updates from CMS and AMA with respect to COVID-19 and telemedicine, and a changing service delivery that increases the need for coding expertise. The shortage of workers is driving providers to take a fresh look at business process outsourcers (BPOs), which can provide healthcare coding expertise at a fraction of the cost of onshore workers.

2. MYTH: Offshore coders do not understand US regulations.

FACT: Coding specialists don’t need to be trained in the US. Today’s BPOs can provide well-trained and skilled offshore resources.  Sagility, for example, has established a Coding Academy to develop a robust talent pool. The Coding Academy is a world-class coding academy that creates industry ready certified coders who can significantly and immediately add value. Our experienced certified coders are well versed in ICD-10-CM, CPT/HCPCS, National Correct Coding Initiatives, Local Coverage Determinations, National Coverage Determinations and other CMS and payer specific guidelines. Adept at both payer and provider specific coding requirements (diagnostic, procedural and DRG coding), insurance and government regulatory requirements, team members have seeded expertise under SME guidance and cross-trained for related specialties. These team members form the core of a multi-shore capability.

3. MYTH: Outsourcing does not reduce costs.

FACT: The cost of outsourcing is significantly lower than insourcing. BPO coding expertise can represent up to 40-50% discount for first-time outsourcers.domain expertise and clinical specialization to address areas like coding-related denials, which can comprise 30-40% of overall denials. Two-thirds of these denials are not reworked by providers because they do not have time, resources, or skillset to understand and resolve denials. Couple that with an efficient coding and billing process, and a provider can work proactively to prevent nearly 90% of their denials. This lifecycle focus is an area in which coding expertise can deliver, especially those with ecosystem knowledge and multispecialty payer and provider coding delivery. These partners train coding talent from a mindset of dual perspectives—and payer understanding means a more proactive approach for providers with more coding value delivery.

4. MYTH: Coders do not have process expertise or co-create value.

FACT: Coding operations are optimized with innovation and operational excellence. Design thinking, cocreation, and process reengineering are key advantages of BPO, which come equipped with singular process and technology expertise. As innovation hubs that specialize in transformation every day, BPOs can boost coding and clinical expertise with the innovation firepower of automation and analytics skills, domain expertise, and regulatory compliance. For example, solutions such as intelligent analytics enable service vendors to help hospitals stay ahead of the curve to predict potential denials that flag for additional reviews before a claim is sent out to prevent denials. These solutions are supported by customized dashboards to describe top denial reasons, top denied procedures, modifiers, and diagnoses. Finally, with centralization of these coding resources, changes in systems, regular coding updates to stay current and compliant can be implemented quickly and efficiently.

5. MYTH: Coders are not specialized.

FACT: Certified coders are specialized by coding area. Coders gain expertise in specific specialties that are not easily interchangeable. For example, an office coder may not be an expert in coding surgery or anesthesia and vice versa. Similarly, coders are not necessarily experts in resolving denials. Managing a coding denial requires experience and knowledge beyond coding. It is hard for a provider to find a coder meeting their specialty requirement which may result in revenue loss or upcoding resulting in non-compliance against coding regulations. For example, clinical denial-trained coders know how to resolve denials.

The BPOs that can best solve for today’s coding challenges have extensive ecosystem experience working for both providers and payers, giving us a unique exposure to understand both worlds. Our training and best practice sharing are designed to enhance our coders on both teams to prevent denials happening in the first place. By rightshoring the work, our clients can immediately save 40-50%, which goes beyond the cost of labor – finding the right skillset, overhead to work on preventable denials, cost to manage operations, quality, and infrastructure. Through our technology-enabled coding solution, we can reduce coding denials by 50% and will stay you fully compliant with federal regulations.

In recent years, the healthcare industry has increasingly been paying attention to the error rates in health plan directories. Undependable directories create poor member experience by impacting access to care. The Consolidated Appropriations Act COVID-19 relief bill, signed into law on December 27, 2020, requires health plans and healthcare providers to work in tandem, so that members are informed and protected.  This law, under the No Surprises Act, an interim final rule recently passed, mandates that health organizations ensure provider directories are current and accurate. Currently this Act targets an effective date of January 1, 2022, with health plans required to verify provider contract status and updates every 90 days. Health plans and organizations that do not comply face penalties and both member and provider abrasion.

As Provider Network Operations is increasingly at the fulcrum of both health plan operations and optimized consumer experience, here is how operations experts such as business process outsourcers (BPOs) can efficiently and effectively address the three aims of No Surprises:

1. Health plans need to update provider directories and respond quickly to consumers.

The No Surprises legislation requires health plans to update their database within 48 hours of receiving demographic change requests from a provider.

How BPOs Can Help: The right operations partner can provide the people, process, and technology expertise to update directories with speed and quality.This enables real-time provider demographic updates. This output can be either shared through an automated nightly batch run that updates the plan’s database directly or as an output file in any desired format. Additionally, dashboards can provide visibility and ensure compliance as well as access to data that can help drive process refinement specific to the experiences (such as, if a provider prefers phone outreach or responds to phone outreach, but does not respond to email outreach, processes can be refined based on the data we have collected based on the experiences to reduce provider abrasion). These insights go a long way toward both No Surprises compliance and the enhanced Star ratings and reduced provider abrasion that support optimized experience.

2. Regular verification of provider contract status and updates is required at least once every 90 days.

How BPOs Can Help: Provider Data Verification and Collection modules can help to conduct planned outreach campaigns to collect provider data. This data collection and verification activity can be performed outside of clients’ core systems and the application can provide cleaned output files in most industry-standard formats.

The verification aspect of network management is complex, as all providers and provider groups have different communication preferences. The right BPO partner will have customized applications, as well as multimodal outreach processes that use three different communication channels:

• Phone
• Email with link to online self-service portal
• Fax

Another network management challenge is reaching out to providers without adding to their workload. Traditionally, most provider verification campaigns for updated directory information are run by fax or phone. While provider outreach can be supported via fax, phone, or email depending on what works best for a particular office, the ideal option is directing providers to an online pre-populated form. Providers can easily update their information without having to deal with pesky manual forms or spend more time over phone, and health plans receive updates quickly and efficiently.

3. Healthcare providers must communicate information more frequently to health plans to verify accurate directory information.

How BPOs Can Help: Today’s providers must respond to a constant flow of requests that taxes resources and adds to cost. Network management experts can provide tools via customized auto-reminders to the contact person at practices, alerting them that it is time to attest demographic information pertaining to their providers.

All of these No Surprises mandates are on the horizon—along with the requisite additional oversight and compliance. On the bright side, today’s healthcare organizations can seize the moment and accelerate their drive toward a more B2C healthcare experience. And BPOs have the required core solutions to get them there faster—with critical No Surprises compliance and also the solutions to meet of the ever-raised bar of optimized provider experience, accurate provider data/directory, and improved and more cost-effective processes. When accurate information is made available on consumer directories, millions of members are empowered to make the choices that are best for them and their families.

Capturing a consumer’s emotional response to a service or sales experience is increasingly vital to their interaction with a brand. The pandemic has made this fact increasingly clear, with both healthcare payer and provider operations accelerating digital delivery of member/patient experience. Emotional analytics and innovation to enhance healthcare interactions, using digital emotional signaling, are a means for brands to acquire and retain consumers. That is because healthcare interactions support that merges digital solutions with empathetic analytics can play an essential role to measure the moods, attitudes, and emotions that garner brand preference and loyalty.

A recent study by Tempkin Group showed when individuals have a positive emotional association with a specific brand, they are 8.4 times more likely to trust the company, 7.1 times more likely to purchase more and 6.6 times more likely to forgive a company’s mistake. Although sales figures, surveys, social media posts, and ratings may help inform brands about customer views, they do not provide the finer, granular insights regarding what goes unsaid. And existing conventional measures cannot intercept brand bias since they focus on measuring the probability of specific customer reactions while the customer is already having a biased outlook towards the brand.

As healthcare organizations continue to focus on improved operations and real-time insights that drive customer satisfaction, frontline resources are becoming increasingly dependent on data to improve the customer experience. But driving real time insights is less and less achievable, as current systems are disparate—across technology, locations, and resources—and they do not achieve a unified or real-time interaction insight. Additionally, real-time feedback is increasingly difficult —with the proliferation of channels adding to the siloing of reporting data. As this shift continues, operations are searching for more ways to provide instant impacts to the programs that they manage. Healthcare organizations need real-time tools that provide immediate insights into the condition of their interactions and the program overall.

Today’s analytics solutions solve for three key customer experience truths for healthcare consumers:

• Today’s digital-led customer care must meet the needs of Generation “C”, the “connected” customer demographic that spans generations. These consumers make purchasing decisions based on brand reputation and a more personalized experience. A strong digital toolkit of home-grown assets containing Interaction Analytics; AI-Powered Data Capture; and Intelligent Automation will elevate and customize engagement to earn and retain these buyers.
• Even in the face of all the digital, people still make decisions based on emotion. Consumers form an opinion about a brand even before they have shared any real-life experience with them. Any conversation or dialogue with that brand either counters or reinforces those subconscious thoughts regarding the brand. This bias is based on how the customer feels as he or she is experiencing issue resolution or any other service support.
• Healthcare organizations, now more than ever, require extreme efficiency and speed, reduced costs, improved CSAT, quality and Star ratings.

How do you solve for these truths? Healthcare organizations are understanding the need to step up yesterday’s analytics products with a next-gen approach that builds on what is available today. Analytics partners set themselves apart with domain expertise, custom-fit solutions, tech agnostic solutions that are customizable to client needs, innovation and value maximization to leverage proven methodologies and best practices. Sagility brings analytics to drive next-level empathetic experience, with results such as the interaction analytics we recently deployed for a leading healthcare payer. This solution resulted in a nearly 80 NPS score for the client’s Medicare member base—significantly beating the industry standard of 27 . With a combination of tools and strategy, experts can bring these experience solutions to meet demand with next-level ROI to engage and retain members while also delivering both essential insights and operational savings.

First published on May 23, 2018, by Austin Ridgeway, Director, Sagility; refreshed on June 1, 2021

Over the past couple of years, there has been a lot of industry buzz about what retail can teach healthcare about engagement strategies. Now it’s time to walk the talk, with many watching and learning from disruptors.

Healthcare has, undoubtedly, made B2C strides toward 24/7 optimized experience—from nurse triage to customer relationship management (CRM) and analytical population health management (PHM) data collection. Both payers and providers are more proactively tracking member and patient interactions to build intelligence for future interactions. Data collected is building on previous elements, fostering a holistic portrait of healthcare consumers, creating the foundation for predictive intent, and providing a more effortless experience.

Leaning heavily on these new strategies, healthcare is catching up to retail’s disruptors—from digital convenience to personalization. It’s important to remember, however, that the road to engagement is not an easy one for healthcare. The Uberification of healthcare metaphor notwithstanding, retail-to-healthcare engagement comparison is far from an apples-to-apples scenario.

There are key differences between other industries and healthcare organizations, which have to navigate distinct market complexities.

1. More stringent compliance

When it comes to protecting member/patient/customer, and partner data, as well as storing it as securely, healthcare carries a much heavier risk and burden than most other industries. The cost of attaining and maintaining regulatory compliance is high, in terms of costs and resources.

At the top of the list for healthcare is the heavyweight Health Insurance Portability and Accountability Act (HIPAA), which changes daily with the onset of telemedicine and wearable devices that store protected health information (PHI).

Undeniably, the healthcare compliance list is long, and a moving target. With all of the state and federally driven mandates, payers and providers know that even the smallest mistake can result in sanctions by the government, resulting in high costs, oversight, and extensive auditing. So, while functionally, other industries focus on certification and compliance, healthcare has to abide by a broader pool of more stringent regulations.

How BPOs can help: Credible healthcare business process outsourcing (BPO) organizations with reach and a diverse client base not only have a practical comprehension of the broader federal regulations but also benefit from the granular knowledge of state-driven certification requirements and understand the implications of conforming to these regulations.

As expert problem solvers, they have the best exposure to the understanding of the nuances of regulations and how they can affect business from an end-to-end perspective. The global reach of these service providers allows for rightshoring models that ensure that compliance standards are met while still providing cost and operational optimization, with the implementation of new tools such as robotic process automation (RPA).

2. Multiple customers

If the “customer is always right,” then who is the customer in healthcare? Ask any supplier, and they may question whether they serve physicians, patients, hospitals, or insurers.

Healthcare payers and providers have many users and influencers across all operations. Payers aim to engage and satisfy members, providers, and potentially other stakeholders such as third-party administrators. Providers answer to patients, payers, and other parties who have a stake in their success.

Unlike retail, the healthcare industry presents a complex lifecycle of stakeholders with financial impacts. These parties are all influencers of market position, image and, ultimately, success.

How BPOs can help: BPOs can help to address these market challenges, as the right partner will have holistic healthcare lifecycle management expertise that builds long-term relationships to engage and offer exceptional service execution to members, patients, and other relevant stakeholders.

Outsourcing partners typically have a capability set that expands across numerous functional areas within payer and provider organizations. BPOs with a consultative approach will provide the abilities to manage the expectations of all relevant influencers, from voice to back-office operations. This understanding of upstream and downstream impacts will also assist with driving efficiencies and cost-saving opportunities.

Ultimately, as a virtual extension of healthcare client operations, a good partner will carry the customer-centric solution thinking that has led other industries to healthcare interactions success.

3. Internal silo-ization of these orgs

Keeping in mind the bureaucratic and complex nature of healthcare processes, there can be organizational silo-ization that occurs within operational business units. Take, for example, internal decision-making for a health plan’s provider engagement, which could roll up to another leader than the one who owns member engagement. In this classic example, there can be disconnects, causing higher costs and other operational inefficiencies.

How BPOs can help: Considerable advantage will be found with a BPO partner that has end-to-end understandings and capabilities across the entire healthcare ecosystem. These service providers, like Sagility, are experts at centralizing operations to ensure consistency across all operating units and offer exceptional experience and improved outcomes.

Ultimately, to navigate these unique industry challenges and finally deliver the customer experience found in other buying scenarios, healthcare will increasingly look to the essential accelerators.

Data analytics, RPA, AI, and machine learning are key enablers to healthcare transformation—from the way physicians are educated and practice care to how payers support care delivery. With proven success deploying these innovations, along with customer care learnings from more mature industries, BPOs can help healthcare clients to pave the way to truly improved customer, member, and patient experience.

U.S. hospitals lose $262 billion due to denied claims each year, representing roughly 10% of the total claims paid.

Unraveling the root cause of denials costs an average of $118 for each hospital claim, with 60% to 80% of those denials typically recoverable on appeal. For an average hospital submitting 200,000 claims annually, that represents over $2M in potential rework. Hospitals typically lose 2-3% of net patient revenue from claim denials.

The reasons that insurers give for clinical denials vary widely, but commonly include “prior authorization missing,” “not medically necessary,” “experimental or investigational,” “length of stay,” and “treat in a lower level of care setting.” What is not commonly understood is how the reasons relate to the clinical root cause, what medical documentation is required to support the service, and how the payer’s clinical policies relate to the denial decision.

Facing the need to solve for denials from multiple payers with varied clinical policies, hospitals have traditionally hired nurses and other medical professionals to manually review cases, navigate systems, and liaise with departments to investigate and appeal denied claims. Hospitals frequently run into resource limitations with this conventional approach. Today, maybe 20% of clinical denials can be appealed with this method.

Successful clinical denial resolution requires a clinical skillset to research the root cause and to address the patient’s medical situation and appropriate payer criteria in an appeal. Applying modern technology — such as analytics, automation, and artificial intelligence (AI) — can help to increase the number of clinical denials investigated, boost appeal effectiveness by addressing true payer clinical policy root cause, and recover much-needed revenue.

Analytics

Definition and context: Analytics is a mechanism for extracting meaningful insights from an organization’s existing data for better business decision making. Data are extracted from many source systems; cleansed, integrated and stored in a data lake; enriched and synthesized with the latest AI and analytics tools; and then rendered in reporting dashboards for decision-makers.

Potential analytics applications for clinical denials:

• Indicate the propensity to overturn denials based on payer, denial error, procedure code, and diagnosis.
• Identify trends in clinical documentation integrity by service and common payer clinical criteria.
• Identify potentially uncollectible codes through prior appeal trends.

Automation

Definition and context: Robotic process automation (RPA) uses existing end-user software interfaces and enterprise applications to automate processes to reduce effort and bring in process efficiency. Full and hybrid/blended (with human intervention) automation approaches are possible. Automation leads to better capacity handling, faster processing, fewer errors, reduced penalties, better compliance, and cost optimization.

Potential automation applications for clinical denials:

• Appeal templates for faster and accurate processing.
• Automated prior authorization workflows to negate denials for missing authorizations (up to 10% of ACA plan claim denials relate to prior authorization).
• Image recognition to facilitate automated routing and standard appeal follow-up on common clinical denials.
• Clinical data integrity through automation using common denial sources from patient and provider data.

Artificial intelligence

Definition and context: While RPA has helped to automate rules-based, structured data and processes, cognitive automation is the process of identifying and processing unstructured and semi-structured data. Cognitive automation brings much needed artificial intelligence into rule-based RPA. Cognitive elements such as machine learning (ML) and natural language processing (NLP) can make sense of data that appears to lack patterns. AI goes one step further than RPA by enabling machines to execute subjective processes requiring decision making.

Potential AI applications for clinical denials:

• Verify required medical documentation for frequently denied services and flag tagged portions for clinical review.
• Digitize the request process for commonly required medical records when a patient’s file is missing outside physician records or other specialist encounters to support denied service.
• Provide a summary (for a clinician) of the patient’s associated medical condition related to applicable payer clinical criteria.
• Generate appeal letters based on medical records for clinician review for common conditions and denied services.

In clinical denials, a technology-led approach increases the number of appeals that the hospital is able to address, revenue collected, and effective clinician allocation. Analytics, automation, and AI can improve root-cause analysis based on underlying payer clinical criteria while both refocusing and minimizing processing tasks for staff.

Up to 90% of denied claims are preventable. Rework is preventable. With the help of technology, medical professionals can optimize research, decrease overall denials with key prevention strategies for medical documentation and billing, and reduce time spent on uncollectible accounts.

Get more ideas on how to use analytics, automation, and AI for revenue cycle management in our “Accelerating claims reimbursement with Sagility clinical denials advanced recovery” case study and our “Recover lost revenue: Leverage AI to automate your revenue cycle” whitepaper, which offer insights on how to use technology to maximize provider revenue.  

Across the healthcare industry, health information mismanagement is causing a loss of millions of dollars each year. Inefficient use of staff resources and systems, or the failure to invest at all, reduces a healthcare provider’s already thin margins. Provider finance leaders are struggling to address the financial impact of post-pay audits, denials, and processing appeals, while revenue cycle departments are inundated with backlogs of denials on previously paid claims, distracting them from standard claim resolution processes.

Proper revenue cycle management (RCM) involves careful documentation of the entire patient journey, from pre-registering through payment collection. The solution for streamlined, successful RCM requires hiring for the right skill sets and leveraging the right tools to track and analyze patient and member data—and healthcare organizations must prioritize this challenge.

Seek out these associate attributes

Because each detail of a person’s path of care must be recorded accurately, the ideal candidate for this type of work is meticulous and adheres to the many and varied processes that payers provide. Timeliness is essential, as is proactive self-motivation to ensure each step is completed. An ability to communicate effectively with multiple people and departments, along with knowledge of medical terminology, are essential skills.

Perhaps the most desirable skill is familiarity with or the aptitude to quickly grasp the tools and software used to perform data collection, analysis, and reporting. Although technology-enabled RCM services are widely available today, many organizations are running on antiquated systems that fail to integrate with more modern options, which contributes to inefficient operations and additional lost revenue.

Track it all with the right tools

Once captured by a proficient employee, patient and member data can be handed over to artificial intelligence (AI)-based systems. Machine learning (ML) and Natural Language Processing (NLP) help reveal insights from the information gathered, and predictive analytics can provide recommendations based on patterns detected.

Although critical, patient and member data isn’t the only information to track. The work performed by employees and the tasks themselves must also be monitored. With good data and analytics in place, key performance indicators can be reviewed and improved upon regularly.

A recent article in Becker’s Hospital Review states, “By effectively tracking your issues, you can improve your revenue cycle by prioritizing the issues with the largest impact on fiscal management, revenue cycle processes and workflows and ensure personnel are held accountable to meet target dates and goals.”

A huge source of revenue leakage is due to post-pay recoupment, according to Belinda Cridge, Director of Client Services at Sagility. Although the contracting and revenue cycle management functions previously worked in silos, she says, “Contracting now proactively reaches out to the billing and follow-up folks to check on issues related to post-pay audits while they go into new contract negotiations.”

Cridge adds that although there’s no way to estimate or predict the number of upcoming recoupments, proactive tracking is important. “Set up your system to be able to track recoupment and to track audits,” she advises.

Sagility Director of Client Relations Matthew Betts agrees. “You definitely need a tool to track and monitor the information, and you also need resources who know how to use that information to prevent denial kickbacks, manage the audits, and provide upward feedback with leadership.” Information needs to be incorporated into your denial reduction initiatives in a timely fashion to prevent further revenue leakage in future audits.

At Sagility, we’re known for both our service capabilities and analytical expertise.

Health plans are all too familiar with the challenges of member experience—that perfect storm of call/processing volume surge, staffing challenges, and critical moment-of-truth engagement pressures. And the stakes are even higher for 2021, according to JD Power research.  The organization’s fourth annual study found that member satisfaction averages dropped from 712 on a 1,000-point scale in 2009 to 701 in 2020. J.D. Power and Associates measures health plan satisfaction of 133 health plans in 17 U.S. regions in seven areas: coverage and benefits, provider choice, information and communication, claims processing, statements, customer service, and approval process.

To be successful, today’s digital-led member engagement must meet the needs of Generation “C” – the “connected” customer demographic that spans generations. These consumers make purchasing decisions based on brand reputation and a more personalized experience. A strong digital toolkit, containing interaction analytics; AI-powered data capture; and automation, will elevate and customize engagement to earn and retain these buyers. It may be counterintuitive, but digital enablers such as analytics, AI-powered intake, and bots can deliver a more empathetic, customized member enrollment experience—one that earns and retains customers for life.

Analytics

Interaction Analytics solutions offer key advantages along all consumer journey touchpoints, delivering essential ROI with voice of consumer insights related to preferences and experience enhancements to drive higher CSAT and NPS. Contact centers have a goldmine of customer feedback.Insights can be built from speech data that is a valuable information source of customer sentiment and intent. The data tells the unbiased story here – to avoid missed opportunities or misalignment of feedback. The proactive insights built at the crucial open enrollment phase are actionable by helping health plans to tailor their product development to consumer choice across key member demographics.

Case example: As a value-added service, Sagility engaged with a leading health insurer client to implement VOC analytics. Our solution was deployed to transcribe and analyze millions of interactions. We conducted a deep-dive analysis on negative customer feedback into how claims settlements are made and the customers’ lack of awareness of the benefits provided by new insurance products, especially in the Open Enrollment season. The results included:

• Better correlation between NPS/CSAT rating and call types, driving a solid 33%​ NPS and CSAT improvement.
• A more streamlined and frictionless claims settlement process along with more frequent and clearly defined communication to all customers regarding insurance products and their benefits.
• A trend analysis of member demographics by geography, resulting in better provider network relations.

AI-powered data capture

Today’s cutting-edge machine learning, optical character recognition (OCR), and intelligent character recognition (ICR) for cognitive intake have elevated the document management process once considered highly burdensome for payers. The open enrollment process is a touchpoint ideally suited to intelligent data capture. Open enrollment is a highly paper-intensive process that presents an excellent opportunity for improvement. With the inherent paperwork and processing, AI-powered innovation provides tremendous opportunity for workflow enhancements to minimize subjectivity of structured/unstructured data—for faster turnaround and cost savings.

Case Example: Sagility created an intelligent machine learning solution to help improve a client’s Star rating—a measure directly linked to member experience. The team addressed the entire workflow with a cognitive content processing solution leveraging an image analytics engine to process the source. The solution featured a natural language processing (NLP) engine to analyze key words and context. For one process, this as-a-service solution drove Star ratings improvement of the MA plan by an 8% weighted average. For member experience, this data capture closes the loop, addressing member resolutions via AI for quick, accurate decision making—those functions on which Star ratings are established. With better ratings, step one of the member experience journey—plan selection—is enhanced.

Automation

By bringing greater automation to the open enrollment process, organizations can decrease their labor requirements while realizing a greater return on investment. Bots can streamline the repetitive and time-consuming steps of the open enrollment process for crucial desktop efficiencies that significantly impact customer experience. This “straight-through processing” is the smartest path of least resistance, with a bot-brain approach to address seasonal challenges with intelligence.

Case Example: For a leading health plan, Sagility looked at a process of manual data entry for member details in the enrollment system, starting from intake applications over different formats. For Specialty enrollment, as per this process, the client was converting XML into PDF applications, which were manually indexed and given to resources for entry. Before Sagility’s involvement, there were 12 screens to be filled manually, with requirements of more than 99% accuracy for data entry. For Medical enrollment, applications were coming from brokers with multiple instances of missed information and multiple data entry provisions. Sagility leveraged blended RPA solutions to take Specialty and Medical queues live. For Specialty, we helped drive an increase from 25 to 40 apps daily, reducing costs by 40%. For Medical, we reduced costs by 30%, decreasing the time taken to complete one application by five hours. With these processes, the Sagility achieved $400,000 in annual savings for the client.

The above case examples are proof points to support the fact that BPO partners bring a unique solution mix to address open enrollment: automation and analytics as-a-service capabilities, seasonal talent scale and agility, and right-shoring cost savings. The right BPOs are ideally suited to accommodate needs like open enrollment on the principles of lean operations, and also co-creation, design thinking, and globalization. Beyond cost-cutting, good BPOs implement meaningful changes that help eliminate silos and align objectives in order to achieve true operational and engagement impact.

This year’s open enrollment period takes place from November 1 through December 15, when consumers can select or renew an individual exchange plan either on or off marketplace. For the millions who purchase these plans, the experience can be cumbersome and frustrating as they struggle to make complex decisions based on balancing competing interests of cost, quality, and access.

Because creating a frictionless shopping experience for customers (and especially repeat customers) should be a critical objective for health plans, the federal government has enabled a key technical enhancement to the marketplaces called enhanced direct enrollment (EDE). EDE changes the game for how consumers purchase insurance, and smart companies will optimize the upside available from EDE for their customers.

What is enhanced direct enrollment (EDE)?

When the healthcare exchanges first launched, individuals shopping for plans on a health plan’s website were unable to complete a transaction for coverage without being redirected to HealthCare.gov to first verify their eligibility. This led to confusion as customers were suddenly presented with new slates of options after having initially made a buying decision. In many cases, shoppers had to start over, or they closed out of the process in frustration. Many either never went back or went straight to HealthCare.gov when they felt ready to shop again.

EDE enables health plans and web brokers to connect directly to the Federally Facilitated Marketplace (FFM). Individual customers can complete the entire purchase process and experience without ever having to leave a health plan’s web environment. Plan research, eligibility determinations, subsidy applications, pricing, and enrollment initiation can all be completed in one unified shopping experience. In addition, once enrolled, individuals will also be able to access all CMS notices within the same application.

How does EDE improve the customer experience?

For someone looking to buy an individual health insurance plan for the first time, confusion is likely to be the defining emotional state. A research and purchase experience that includes multiple handoffs or disconnects will compound the frustration and anxiety. Plus, the underlying products—which everyone needs but hopes to never use—provide little inherent excitement or satisfaction.

Health plans spend a great deal of money in customer acquisition every year before the open enrollment period. If they don’t leverage EDE, these health plans risk “leakage” every time a hard-found potential customer is redirected to a federal site that is also prominently displaying competing products. Instead of finishing a purchase on the health plan’s website, they may start clicking around the government website and find dozens of additional options to entice them. In many cases, they may end up purchasing from another plan. This is marketing and advertising spend wasted. By leveraging EDE, the individual stays on the health plan website without having to go elsewhere to finish the process.

For health plans, the EDE functionality is not just another widget or fancy add-on; it’s a key component that offers seamless integration into existing enrollment products and workflows designed to improve the customer experience for both current and prospective members. The Centers for Medicare & Medicaid Services (CMS) has designated a small number of firms as licensed EDE entities, and health plan providers must choose a partner that has done the legwork, development, and testing to ensure their products and processes meet CMS standards.

Providers view prior authorization as a manual, burdensome, and laborious process, mostly because of process missteps such as lack of clinical data integration, inconsistency in data exchange standards, and differing policies among payers. According to a recent American Medical Association survey, handling the surging prior authorization requests translates into a “high” or “extremely high” burden for 75% of physician respondents. And 90% of surveyed physicians reported that the PA process delays patient access to necessary care. An important front-line negative impact of this time-consuming and often ineffective process is that patients feel the brunt of the delays and are disgruntled due to the endless appeals before receiving the needed care.

The rapid maturity in cognitive automation and predictive analytics supported by robust data sources presents an opportunity for payers to evolve traditional utilization management (UM) processes into an intelligent authorization process. What about taking a surgeon’s scalpel to the process, with a more targeted, precision UM? This more precise UM is a proactive data-driven program that uses the power of predictive analytics to provide a prospective view into the downstream needs of the patient, thereby reducing unnecessary repetition of authorization—every step of the way.

The precision UM method not only reduces burden on providers but leads to reduced provider abrasion, enhanced member satisfaction, and decreased administrative resources and costs in managing the authorization process.

Four critical elements of precision UM meet the patients where they are in their care journey:

• Precision analytics: Member analytics looks at member behavior, historical data on compliance with preventive/recommended treatment, comorbidities, and lifestyle factors to accurately predict duration and level-of-care needs. These analytics help provide a prospective approval for the entire course of treatment. For example, a request for varicose vein ablation can be automated through predictive analytics if the historical claims and clinical data show a patient’s lack of improvement with conservative compression therapy and abnormal lab-based venous varicosity. Other lifestyle factors—such as comorbidities or a ground-floor versus an upstairs bedroom—also factor into what additional services (physical therapy or home health) need to be authorized.
• Provider scorecard: The provider scorecard comprises analytics based on compliance to process fraud, waste, and abuse, as well as outcome measures such as accurate and timely information submission. This provides the ability to audit on the back end for continued gold-card status across UM needs and can help drive dynamic changes to the automated authorizations for stringent cost and quality outcomes.
• Intelligent automation of authorizations against clinical guidelines: Using machine learning tools enabled by natural language processing functionality, this innovation can reduce review time by 30-40% and optimize the approval to denial ratio by 20%.
• Care management and care coaching to holistically address the member for better lifecycle outcomes: Upon identification of key parameters driving utilization needs, a holistic care transition and care management program can help members seek only necessary and targeted care needs that will maximize outcomes. Addressing social determinants such as two-story housing when the member has a walker or lack of transport to attend outpatient therapy can reduce unnecessary utilization, optimize recovery timelines, and reduce readmission to hospitalization.

To provide the precision focus above, healthcare organizations are looking for BPO partners with end to-end-expertise and clinical resources to scale support with intelligent tools and workflows to reduce cost and improve the effectiveness of UM programs. These BPOs have the analytics to deliver superior insights with client data, including deep dives to determine root causes of inaccuracies and process inefficiencies. Adoption of precision UM, electronic requests, and interoperable data exchange can significantly improve the payer provider collaboration. Additionally, providers should also consider clinical data audit using NLP solutions, which would increase the accuracy of documentation required for the UM processes.

Rather than expending time and resources to hire or train internal personnel, a skilled BPO organization can bring knowledge and skills in these areas to an organization immediately, with limited lead time. Ultimately, the goal is to develop a partnership that brings precision-UM-focused talent, best practices, and resources to the table.

Across the world, today’s healthcare organizations are sharing one critical challenge: the rising costs associated with improvement in quality care. The underlying mandate is that all stakeholders must keep a sharp focus on making healthcare more effective, efficient, and affordable. To meet this new demand, both payers and providers have made adjustments to service delivery—and technology is increasingly playing a pivotal role.

How can payers and providers leverage technology to better collaborate? In a word: data. The amount of data attached to every patient has grown exponentially—and all of it is gathered, integrated, and interpreted according to compliance guidelines and processes that can vary widely between payers and providers. Additionally, the data sets held by payers and providers can be significantly different. For example, payers possess data on claims, financial analytics, and risk models. Providers have administrative and clinical data that includes case histories and outcomes. Providers need to leverage health plan data in order to move from episodic care to delivering outcomes-based care across the care continuum. Payers need access to patient information in order to work with providers to establish appropriate care plans for their members. In the past, both stakeholders have attempted to bridge these data gaps through costly and time-consuming manual processes. The good news is that today’s more advanced analytics leverage data and improve collaboration of payers and providers—for enhanced experience and decreased costs.

Next-gen capabilities

While the healthcare industry has mastered data collection, the challenge is making it actionable. According to research, about 80% of healthcare data is unstructured, making it extremely difficult to apply against business or clinical challenges, including population health management, countering fraud, waste and abuse and other administrative and financial transactions. And even the 20% of structured data presents enormous challenges in a value-based care world—with different data sets kept by payers and providers. Emerging cognitive capabilities increasingly address issues of unstructured data. And implementation of advanced analytics techniques and usage of new visualization tools provide the ability to pull information from disparate data warehouses while keeping data quality measures in place to make the data ready for analytics, with uniform and up-to-date information available across the organization.

Another area of data mining evolution is today’s predictive analytics models, which lean heavily on data and machine learning algorithms to project the likelihood of future outcomes. These predictive analytics can be used to predict more accurate payment and identify intake weaknesses and care to improve both healthcare delivery and patient experience. These models can generate recommendations based on patterns identified in the information gathered, thus allowing the organization to deliver services more efficiently. Additionally, artificial intelligence (AI)-based systems can reduce administrative burden by providing cognitive decision-making capabilities previously dependent on human effort.

Whether on the front end of patient treatment or downstream, at propensity-to-pay, these advanced capabilities bring many advantages, including:

• Poor communication and inaccurate data contribute to provider abrasion. Today’s CRMs, as a goldmine of patient, physician, and health plan data, serve as a common ground for both providers and payers—a source of accurate information that plays a major role in a more streamlined, efficient payment process.

• The preauthorization required to approve a procedure usually consumes significant time and effort for payers and physicians. The advantage of machine learning and natural language processing enables today’s enhanced image processing to dramatically reduce the number of incorrect approvals and decrease incorrect denials. This preserves high-tier resources and avoids costly redundancy of claims reprocessing.

• A more predictive, proactive analytics approach can reduce new medical record requests by singling out process breakdowns to identify error rates for each provider.

• Predictive data can find and address key inefficiencies in the operational management of healthcare business operations.

Today’s BPO organizations are applying innovation to the modern challenges facing healthcare, including data management and integration and predictive analytics. BPOs not only have claims data from provider groups, but also, payers. Armed with this intelligence, providers can positively affect a patient’s health outcomes, through PHM processes that also bend the cost curve.

BPOs can also bring the strategy and best practices gleaned from years of capturing, processing, transforming healthcare data from all states of the process–from pre-authorization and claims submission to customer care insights. By choosing the right BPO partner, healthcare organizations can align with tools and expertise to reduce abrasion and better navigate the changing ecosystem, while positioning themselves and their consumers for optimized engagement and outcomes.

Provider healthcare technology has progressed rapidly to advance clinical care. Despite the leaps forward in provider technology, innovation has been comparatively slow for most providers’ financial processes.

Smarter management of insurance accounts receivable (A/R) is an area urgently needing renewed focus to augment healthcare’s drive towards improved cash as well as stringent cost control.

Left unattended, insurance A/R indicators show that, in some instances, gross charges denied by payers have doubled to 15 – 20% of all claims submitted, with the potential for 40 – 60% of those denials recoverable on appeal. Recoveries like that should be incentive enough to find ways to move forward quickly with new processes and new technologies to manage these denied claims.

Revenue cycle management (RCM) issues and inefficiencies have many root causes, from weak clerical skills to outdated or abused technology.

It’s a fact that some health systems have complex, poorly integrated and often outdated technology. Many legacy accounting and patient billing systems are 10 – 25 years old and not capable of meeting the needs of a rapidly changing healthcare reimbursement environment. It is quite possible that a junior revenue cycle professional may be working in a billing system that is older than they are.

Many of today’s revenue cycle organizations are reluctant to adopt disruptive processes and technologies, simply from a natural inclination toward protecting the system’s assets.

A recent Black Book CFO survey stated that few provider organizations are widely engaging in hospital financial automation. Only 20% of the 1,600 hospital and health system CFOs surveyed said even a small part of their organization’s financial and revenue cycle operations were fully digitized or automated. Amazingly, those who digitized more of their financial process said the ROI was substantial.

STRATEGIES FOR IMPROVEMENT

Healthcare organizations can significantly improve what they capture from payers (known as their contractual payment ratio), as well as accelerate recoveries by focusing on these four key areas:

1. Invest in your front office. Recruit, onboard, and train your best people to optimize operations. At the front of the house, capture good information and give your patients a clear view of their financial obligations; this will pay big dividends in patient satisfaction.
2. Ensure accurate coding and supplemental clinical documentation supported by optimized processes and technologies. The latest hospital coding compliance technology will help to identify and correct processes that lead to claim denials. Robust coding processes and contract compliance automation systems help hospitals to get ahead of coding and medical necessity denials, with the added benefit of educating coders, financial analysts, and providers on how to submit clean claims the first time.
3. Maintain a fast focus on denials. Today’s payment variance reporting can identify underpayment and overpayment trends for analysis with broad-reaching, sustainable return. Highly effective tools, such as chargemaster assessment tools and concurrent charge integrity tools, are not currently being widely used. Prevention is key but, at the same time, addressing denied claims within 24 hours of receipt is critical to optimizing appeals success
4. Understand the difference between denials and rejections and know what workflows must happen for each. Rejections can cause a great deal of wasted effort. It may help to think of rejections as the end of the story, with payment a lost hope unless the account is reworked from the beginning. Denials, on the other hand, are an opportunity to identify the probability of payment whether the payer’s request is for authorization, coding, or additional information. Denials need immediate response from a trained group who can quickly:

• Define the needs raised by the payer
• Address shortfalls according to payer protocols
• Prepare root-cause analytics to address internal issues and errors made by technologists, technicians, and physicians in the revenue cycle’s process

A NEW FOCUS

Once the areas above are addressed, healthcare organizations can focus on scalability, optimizing the quality of data reporting to payers and regulators, and navigating the reimbursement structure of covered charges, provider liabilities, and growing out-of-pocket expenses for their patient-consumers.

The answer is a team approach to denials management: Determine the sources of the health system’s denied claims and address them head-on.

Claims denials will never fall to 0%. However, health systems find benefits from being equipped with trained and motivated staff, aggressive processes, and innovation necessary to recoup the dollars denied by payers and thereby contribute to the organization’s financial sustainability.

Imagine this scenario: You are in the hospital after an emergency appendectomy, and you have a simple but urgent question about payment of this (just-delivered) health service. Your physical and mental stress is a load made only heavier with that pending insurance coverage conversation. You are in no mood to struggle with an exasperating app or digital exchange. You want a straightforward, reassuring dialogue—one delivered with good, old-fashioned empathy.

From the other perspective, the bar has just been raised for your engagement team. The right customer service agent has to deliver on several levels: as an empathetic advocate who can listen, relate, and also resolve the issue at hand. Simply put: With all of the renewed—digital and otherwise—efforts towards optimized healthcare interactions, healthcare customer service remains highly challenging.

The recent COVID-19 surge has exposed healthcare interactions teams to an all-new type of issue, one which no bot or digital channel has ever dealt with, to date. What’s needed is a fresh approach to empathy-based engagement as part of healthcare customer experience.

Now is the time for healthcare to learn a few lessons from technology-retail elites like Apple, which is actually renowned for its very untech-like empathy focus. Apple aims for Geniuses to walk a mile in someone else’s shoes and to recognize the emotions their customers feel and change those, to make them feel better. The Apple manual advises the “Three Fs: Feel, Felt, and Found.” This means connecting, relating from personal experience, and consoling with issue resolution. Healthcare would do well to borrow from this model and reduce friction points for more effortless, empathetic problem solving.

Ultimately, there is still a strong foundation for every contact in healthcare—charting of a basic blueprint for compassionate issue resolution. An optimized experience, delivered by an agent empowered to deliver empathetic customer satisfaction, should comprise this flow:

Step 1. Empathy begins with active listening. From the first word spoken by the customer, the agent needs to be focused 100% on the communication at hand. This point in the conversation is critical as an opening to bond and win immediate customer trust. Agents shouldn’t make notes while listening; unless they listen properly, they cannot react to the situation of the customer. Reduce any miscommunication with follow-up questions.

Step 2. Acknowledge the customer with member/patient name and personalize the communication with a concierge touch to earn trust and loyalty. By using unified desktop and disparate systems, today’s agent can pre-emptively acknowledge the issue at hand without spending time on a longer intake. There are also opportunities to track prior visits to eliminate abrasion with unnecessary restating by the member/patient.

Step 3. Show understanding and calm. The adage is that you never truly know what a person is going through. But with healthcare, that goes out the window. Because one thing has been made clear with healthcare customer calls, and that’s that the member/patient’s life is, in fact, being affected by a health issue. Empathy at this stage might mean a reassuring tone with, “I understand this is difficult. I’m here to help.” Do not interrupt the customer, instead show attentiveness.

Step 4. Demonstrate intent to resolve the issue, with the understanding that it won’t necessarily be the case that everything is within our control. At this stage, it’s key to let members/patients know that empathetic customer care means trying your level best to help, with the understanding that some conditions or procedures simply may not be covered. Aim for  authentic communication, with an added personal touch and thank you or expression of gratitude for patience.

Having been on the front lines of delivering healthcare customer service, we’ve seen how clients have evolved their metrics focus—from quality, first-call resolution, and call center CSAT to NPS.

One emphasis that has remained the same is empathy, as the leading attribute in every single interaction that drives all of these metrics. And while empathy is required for all customer service, in healthcare, even more so, the mission is to address critical, personal impact related to health, finance, and the often raw emotions at the core. Helping customers resolve their issues is a delicate balance of all three of these things.

That’s what makes healthcare customer service as uniquely fulfilling as it is challenging.

Recent reports show that up to 80% of payers are integrating social determinants of health (SDOH) into their member programs. To address this market focus, Sagility recently sponsored a webinar on Best Practices in Addressing Social Determinants of Health Issues Impacting Highest-Need Populations with AHIP. This well-attended event deserved a follow-up session as there were so many great questions from the attendees. On January 15, Sagility shared more essential SDOH thought leadership from our experts Mary Jane Konstantin, SVP and Head of Business, Sagility Population Health Management Solutions, and Tara Page-Haddock, Strategic Product Manager, Sagility Population Health Management Solutions.

Mary Jane kicked off the session with an overview of SDOH, including the importance of focus on the individual level. We level set attendee focus with a poll, “Which best describes how my organization approaches social determinants?” In sum, 32% of our attendee organizations aim to “Address social barriers, with no formal program,” while 27% do, in fact, have a program to address barriers at the patient level. A front-line focus of “Programs to address social issues within my community” was the response for 23% of our attendees, with 18% “Routinely assessing for social barriers at the patient level.”

We polled the audience on “Does your program have a systematic approach for face-to-face outreach,” and 59% of attending organizations do not have this approach. This assessment enabled Mary Jane to elaborate on the value of connecting face-to-face with SDoH outreach. She shared the team members—from peer counselors to community health workers, who can make a significant impact on outcomes with a targeted approach.

Following the webinar, our thought leaders answered some pressing questions:

Question: Can you talk about how a resource list does play a role in SDoH programs?

Mary Jane: In our experience, it’s important to make sure that there is some ongoing effort to update the resource list and make sure it’s still active. I think through issues like housing, we can help with not only housing grants, but also paying for utilities. You need to know what’s available in the local community.

I do want to stress that just giving someone a referral generally isn’t enough. You’ve got to make sure that the member stays well connected with the resource. So as you’re thinking through your outreach, make sure that you’ve made some accommodations for those kinds of services. Tara, anything to add on this topic?

Tara: I will add that it’s key to consider the cultural centers and the retirement centers and the social networking that exists within the member’s community. Our work is often detective work, as we search for the availability of often previously unknown resources.

Question: Can you talk about how you can help with SDoH transportation issues?

Tara: Today, there are a lot of partnerships with Lyft and Uber happening in the communities, and it’s really been really neat to see. I worked with a member in a past program who had a walker, and she walked to the bus and grocery store. She needed the bus to get to the pharmacy and her appointments. Her issue presented with the fact that she couldn’t get to the bus and she couldn’t get a ride to those appointments.  Add to that the fact that her walker wheels were only covered every three months for replacements. This is a good case of a transportation issue. It was about getting her durable medical equipment approved outside of the normal parameters, because her usage of her equipment was so much greater than the average individual who had a walker. This is how transportation can be a key element in understanding.

This can be one of the easiest things to solve for—it’s essential to look at access to transportation and what those benefits are. In healthcare, we often assume members are reading their benefits, yet sometimes it’s just about acknowledging that they have the benefits and helping the member access them.

I don’t think we’re saying that transportation is always the key to improve clinical outcomes. But I believe that when transportation presents as a barrier to care and accessing lifestyle life needs, there’s an opportunity there to make that Improvement.

Lifestyles, locations, and surroundings can all have an impact on an individual’s health. Focusing Social Determinants of Health on the individual level leads to reductions in cost of care through driving engagement, outcomes, and results.