Precision Alignment of Prepay Strategies in Payment Integrity

Foreword

Custom prepay strategies are becoming a core strategic focus in payer Payment Integrity (PI) strategies. These precision upstream tactics offer the ultimate goal of providers submitting bills correctly from the outset. By collaborating closely with providers and offering solutions that identify and resolve errors before payments are processed, we can significantly enhance payer-provider relations as well as billing accuracy.

Resolving payment issues earlier in the process not only avoids the administrative costs associated with post-pay processes but also substantially reduces friction. It’s still important to maintain post-pay processes, as 100% billing accuracy is unrealistic in today’s environment. From those post-pay processes, we can continue to leverage data that helps us to build smarter and customized prepay protocols.

Defining Prepay Precision Strategies: A Roadmap for Impactful Outcomes

A well-designed prepay strategy enhances PI outcomes while minimizing administrative burden/cost and ensuring accuracy at the point of submission. Key steps to building precision prepay strategies include:

1. Using post-pay claim data and stratifying risk
   By using historical claims data to detect patterns, solutions can be implemented to focus on potential high-risk claims before payment is processed.

2. Establishing efficient workflows with the highly utilized providers
   Working with the highest utilized providers to establish proactive provider workflows and initiatives will ensure billing accuracy and compliance, especially when payment guidelines are evolving. Real-time feedback loops can inform providers about recurring and common errors to increase first-pass accurate billing.

3. Customizing Prepay Edits & Rule Development
   While there are common cost drivers across PI, not every payer will have the same fraud, waste and abuse pain points. By developing payer-specific rule sets that address each payers most common cost drivers, we can eliminate specific fraud risks and compliance concerns. The most common areas to start are specialty-driven, high-dollar procedures, the most common outlier billing patterns, and medically unnecessary services.

4. Continuous Monitoring of Regulatory Alignment
   It is always important to monitor legislative shifts and reimbursement policy updates to ensure prepay strategies align with compliance requirements. We can assist in a  overnance process that establishes adaptive workflows. By having set reviews and flexibility in the process, provider alignment tactics can be modified as new laws and regulations come out that impact administration and payments.

Aligning Pre-Payment Strategies for Maximum Impact

Prepay audits are most effective when managed with precision. With the right data and technology, payers can more easily develop the workflow structure to prevent issues from recurring.

To maximize the impact of prepay strategies, several key approaches can be implemented:

1. Streamlining Documentation and Coding Requirements
   Ensuring that documentation and coding guidelines are clear, standardized, and accessible to providers reduces errors at the point of claim submission. By setting specific coding protocols and providing pre-check tools, payers can prevent misinterpretations that often lead to payment delays.

2. Implementing Provider Support Tools
   Empowering providers with intelligent claim submission tools and direct payer support ensures claims are submitted correctly and friction is decreased. It is also helpful to build dedicated payer-provider communication channels for faster query resolution and pre-submission checklists that providers can use to verify claim accuracy.

3. Establishing Pre-Service Billing Verification
   Creating a pre-service billing verification process ensures that claims meet basic payer requirements before they are submitted. This will prevent unnecessary rework and unexpected denials. By confirming key details upfront, accuracy can be validated.

4. Using Analytics to Identify Patterns of Erroneous Billing
   Analytics can uncover trends before claims are paid. Implementing real-time claim scoring models can alert payers to potential compliance risks, and conducting pattern analysis upfront can detect upcoding and unbundling in advance of submission. By identifying recurring issues, payers can refine policies and provider outreach efforts to minimize costly mistakes.

Measuring Success: Key Impacts and Metrics

Implementing precision-focused prepay strategies should garner key improvements in PI. Below are the key impacts of these strategies, along with some of the key metrics that can be used to determine success:

1. Reduced Claim Rework and Post-Payment Disputes / Lower Administrative Costs
   Prepay precision reduces the volume of incorrect, incomplete, or non-compliant claims that require additional processing or post-pay recovery. By ensuring accuracy at the point of claim submission, payers can avoid costly and time-consuming rework. Metrics that can be put into place to track success include:
   ◦ Percentage of claims flagged for manual review
   ◦ Reduction in post-pay audits and disputes
   ◦ Administrative cost savings from adjustments and reconsiderations

2. Enhanced Provider Satisfaction and Reduced Friction
   By proactively working with providers and applying transparent, evidence-based prepay rules, payers can reduce friction and strengthen provider relationships. When providers understand why a claim is flagged before submission, they can make necessary corrections early, improving approval rates. Metrics that can be put into place to track success include:
   ◦ Reduction in provider complaints
   ◦ Increase in first-pass claim approvals
   ◦ Surveyed provider satisfaction scores

3. Improved Cash Flow and Payment Accuracy / Faster, More Reliable Reimbursement
   Ensuring only valid claims are approved upfront results in faster, more predictable payments for providers and more controlled costs for payers. This helps prevent delays and inefficiencies in revenue cycles, stabilizing cash flow and ensuring compliance with contractual agreements. Metrics that can be put into place to track success include:
   ◦ Average days to process a claim
   ◦ Reduction in outstanding claims backlog
   ◦ Reduction in overpayments and recoveries

Conclusion

Precision prepay strategies continue to evolve to proactively address billing errors, reduce administrative burdens, and optimize financial outcomes for both payers and providers. As healthcare regulations evolve and cost pressures increase, payers that adopt precision-driven prepay models will be better positioned to improve financial performance, reduce waste, and enhance overall PI. The future of PI lies in proactive intervention, ensuring that claims are processed right the first time.

CERIS has partnered with payers across the nation to support their payment integrity program and help them advance where they are in their journey.