All payment integrity programs are not created equal. The process for implementing a payment integrity program will look different for every healthcare plan — and for good reasons. However, it is possible to successfully implement these differing payment integrity programs in under 90 days with the right business partnership and aggressive (yet very achievable) tactics and strategies.
90 days might seem ambitious, but, when payers work with a partner that is capable of bridging any gaps in the implementation process, it is possible to achieve swift implementation timelines. When we approach all client relationships as true business partnerships, it benefits all areas of every program execution. Our operational execution is second to none, our team is stacked with experts with decades of experience in the payment integrity space, and our TrueCost solution offers transparency, client-driven control, customizability and flexiblity to meet every need. These factors are what sets ClaimLogiq apart — not just during the implementation phase — so we’re ready to move as fast as our clients can when it comes to crossing major milestones of any program implementation.
Every payer has its own systems, preferences and processes in place to best utilize internal team members for their payment integrity programs as well as communication when it comes to their provider network. Healthcare payers also have different systems and workflows for complex claim reviews such as for DRG validation and itemized bill reviews. This presents challenges when it comes to data exchange, one of the very first steps in any program implementation lifecycle.
However, with any successful implementation of a payment integrity program, there are common elements that can be addressed to make the process simpler and less complex. Specifically, there are four major components to every payment integrity program implementation that are known factors that center around data exchange, program workflow design, provider relationships and outside/third-party integrators and integrations. And, with the right strategy, these milestones can be tackled for faster, accurate and stronger implementations, producing a program solution ready to speed up payment timelines for all stakeholders.
When payers choose ClaimLogiq, we know that implementation is the critical first step to get up and running, deliver on promises to members, and work in harmony with providers to benefit the healthcare ecosystem in ensuring the right claims receive the proper payment, the first time.
That’s why we’ve created an optimal environment addressing the typical headaches of any payment integrity program implementation so payers can be ready for go-live in under 90 days.
1. Data Exchange
Gaining Access to Claim Data Feeds
Once implementation has been kicked-off and requirements have been given the green-light, data exchange becomes the first major obstacle that must be overcome for a successful implementation.
For both pre and post-pay claim review programs, not knowing what the claim feed looks like or how to gain access is the first major milestone to cross in any payment integrity program implementation. IT teams often hold most of the knowledge around data feeds. And it’s for this reason that Payers should begin to integrate claim feed and data exchange conversations with their internal IT teams as soon as possible. Bringing IT teams together, at both ClaimLogiq and at Payers, as the first step will determine what the process looks like and how to get access.
We know that when Payer implementation teams need to reach outside of their team to IT for data exchange information and claim data feed intel, or reach out to other vendor integrations and providers, this adds strain to the timeline. ClaimLogiq’s implementation team is ready to bridge the gap. As soon as we can have ClaimLogiq and Payer IT teams coordinate about data exchange, we can work together with your IT team to develop a way to gain access to data feeds in pre-pay or post-pay seamlessly.
Configuring claim feed file types
Gaining access to the claim data feed is the first vital step in a clean exchange of data for implementation. However, the next step– receiving the claim files– can be problematic, especially as not all claim files are the same type or size. This differing claim file type amongst payers can cause roadblocks for many vendors. This is why it is integral that your payment integrity partner maintains a claim data-agnostic capability. ClaimLogiq is data agnostic. Our technology is capable of accepting all file types – we never dictate to our clients what type we need.
By being claim data agnostic, we can offer faster implementation timelines as we’ve made our solution flexible and capable of adapting to our clients.
Further, other vendors can cause roadblocks with restrictions to which files are needed. If they require a JSON file, you can’t go any further until you’ve converted your files accordingly.
While most vendors need to dictate the kind of feeds and files, all we need is access. We’re data agnostic, so if we can bridge the gap to gaining access, ClaimLogiq can receive any type of files when it comes to claim data.
Without much experience in this area, it can be overwhelming to translate your existing payment integrity workflow from your team to ours. But we can provide the expertise here. We’re more than just a vendor – we consider our clients true business partners.
Simply having our implementation team at ClaimLogiq ready for collaboration with your IT team lets us communicate more efficiently to coordinate and integrate our workflows with yours. This provides a seamless transition to clean data exchange– so that you can get ready to improve productivity and performance.
Action Item for Payers: Collaborate with your internal IT teams and begin communications with ClaimLogiq as soon as possible to understand claim feed access. Once we’ve got access, claim file types aren’t a roadblock for us. We’ll accept all file types and cleanly convert them into a claim review workflow.
2. Flexibility and Control
Designing your payment integrity program to match your needs is critical to a successful implementation and successful outcomes. Outcomes are not just limited to cost savings but provider relations and member experiences. Payers already know what kind of outcomes they’re looking to achieve with their programs and know their own assets, bandwidth, and the capabilities of their internal and integrated teams.
However, Vendors often dictate to payers what their workflow should look like. Because of this, payers are often left with a “square peg in a round hole” situation. When vendors offer a “one-way” solution for payment integrity programs, this leaves Payers to do the heavy lifting, having to manipulate their systems and capabilities to the needs of their vendor. This is not a true business partnership and causes a significant roadblock to achieving implementation in under 90 days.
Transparency, customization, and control are the hallmarks of ClaimLogiq’s software and services. With these foundational elements at the core of our software design and payment integrity concepts, payers can bring us their varying levels of capabilities, and TrueCost can be implemented as it suits our payer partners. TrueCost makes it possible for payers to manage payment integrity on their terms, as our software solution is agile and adaptive, adjusting to the needs of every payer’s claim review program. Payers should think bigger than what they’d previously thought was possible with a payment integrity vendor.
When it comes to the claim workflow and lifecycle, Payers can be ready to come to the table with their needs and outcomes directly addressed. When Payers know how they want to achieve their outcomes and present ClaimLogiq with their capabilities and bandwidth, it’s possible to implement TrueCost with complete flexibility to account for payer-specific workflow needs and requests.
Payers should consider some of the following:
- Do you want to involve your MDs, be a part of the QC process?
- How involved would YOU like to be?
- Because of the transparency TrueCost offers, payers are given real-time access and insight into their claim review process, regardless of in-house or outsourced implementation. Payers can decide how hands-on or hands-off they’d like to be when it comes to working with ClaimLogiq.
- Would you benefit from a customized workflow to adapt to your bandwidth, your team, or your requirements?
- Would you prefer to handle everything from start to finish – perhaps utilize our software in-house? Or, would you prefer to have help from ClaimLogiq’s team of experts?
- How much would you like ClaimLogiq to be integrated with your workflow? Perhaps a hybrid approach (combination of SaaS and full-services) best suits your program needs.
If Payers can design their ideal workflow and know when they want to have control over the program and at what point they will require services or in-house assets, implementation will be that much smoother. Allowing our payer partners to customize their solution and customize the flexibility of TrueCost to meet their specific needs prevents obstacles. When using other vendors, payers need to adjust and manipulate their program needs to fit the vendor’s requirements.
TrueCost truly enables payers to manage payment integrity on their terms. We don’t tell our payer partners how to use TrueCost; we adapt TrueCost to the unique needs of every payer and their individual programs.
Action Items for Payers:
- Understand where you want control over and insight into your program
- Know where in-house team members should be a part of the claim review process
- Know what you need to customize – whether it’s workflows, claim rules, communications, or anything in between.
ClaimLogiq gives our partner clients these choices before go-live. Preparing for where you want to work within TrueCost versus being told what your workflow will look like will have you better prepared for a implementation that is tailored to you, not to the vendor.
3. Provider Relations
Most vendors have pre-set provider letters and communications settings. They decide how your provider relationships look and feel without your input. Since one of the goals of every payment integrity program should be to minimize provider abrasion, requiring that every provider relationship is managed under a “one size fits all” umbrella isn’t ideal.
As a payer, you know your relationships best, so our platform allows you to handle them the way you want to. To prepare, think about how much assistance you’d like from ClaimLogiq around direct communication with providers, customization of your letters, emails, and more. We don’t try to dictate how to manage your precious relationships, so our platform allows you to manage them on your terms. Let us know what you need from us to enable those provider relationships, and we can adapt to that!
You know your provider relationships best. You should decide how they’re handled.
Action Item for Payers: Know where ClaimLogiq fits into this process.
- Would you like us to help with communications, or want to handle it all yourself?
- Should letters be customized with your information or, ours?
- Know your preferred communications workflow with each provider, we will tailor those instances around your relationship needs.
4. Prepare for Any Special Integrations
Do you have other software, technology, teams, or vendors that your payment integrity program will utilize? Most vendors aren’t flexible on how their platforms integrate with others. But with TrueCost’s open API and ClaimLogiq’s implementation team, we can collaborate with any vendor or software you’re already using. And it’s important to note that collaboration and integration can happen at any step of the claim lifecycle. ClaimLogiq and our software, TrueCost, are flexible to meet the needs of your existing relationships and integrations so that we can grow alongside your programs as they evolve.
For this reason, it’s essential to understand how other vendors work in your programs so that when you add an additional partner to the mix, information can be easily exchanged, and partners are prepared to work together. If there are certain requirements for each vendor, coordinating collaboration between vendors to keep each party informed is a great way to prepare for any desired integrations.
Action Items for Payers:
- Outline what the integration requirements are for any third-party vendor, and we can integrate your way.
- Coordinate collaboration between ClaimLogiq and other integrators, we can handle the rest.
With these four major components of any payment integrity program implementation tackled upfront, it is possible for Plans to achieve a go-live to faster payment timelines in under 90 days.
YES! It IS possible to achieve a successful payment integrity program implementation in under 90 days.
At the end of the day, payers know how they want their programs to operate and the outcomes they desire to achieve. Because of this, we give clients the power to decide and manage payment integrity on their terms.
Payers can successfully control the implementation process knowing the four major components that can typically present roadblocks or delay implementation timelines. Payers can be ready for a faster, accurate, and more thorough implementation timeframe in under 90 days if these tactics can be achieved:
- Understanding data exchange, claim feeds, and claim files ready for IT team collaboration.
- Knowing what kind of control and access payers need directly in claim workflows. Ex: Do you want to use your QC experts or ours?
- Provider relationships – what kinds of customizations and communications do you want for each provider, and how do you want it handled?
- Knowing of necessary integrations and third-party integrators: open up communications between all players in the payment integrity program to achieve maximized collaboration and speed up the process to go-live.
With ClaimLogiq, you control the implementation process – we won’t decide how it goes for you. We’re flexible and agile to adapt to every payer’s needs, requirements, programs, and relationships. Because of this, we’re poised to bridge the gap between obstacles to achieving major milestones in any implementation.
A successful payment integrity program implementation CAN be achieved in under 90 days. And by knowing some of the significant milestones to achieve along the way with most healthcare software and payment integrity program implementations, you can be better prepared to overcome any common roadblocks quickly and easily.