Electronic Health Reporter

Responses from Matthew Hawley, EVP, payment integrity, Cotiviti.

Matthew Hawley leads operations and content development for Cotiviti’s prospective payment integrity and fraud, waste, and abuse solutions. He brings more than 30 years of healthcare experience to his role as executive vice president of payment integrity operations for Cotiviti and has been with the organization since 2004.

With the U.S. healthcare system constantly shifting and facing new challenges, it is critical for healthcare leaders to adapt to these changes and leverage proven, technological solutions to solve problems. Here, Hawley shares his insights on how taking a data-driven approach is vital to preventing fraud, waste, and abuse in the healthcare industry and how healthcare organizations can operate more efficiently to optimize patient care.

What are a few significant changes you expect to see in the year ahead, and how can data-driven approaches help healthcare organizations navigate these shifts?

The U.S. healthcare system has been experiencing a rapid evolution marked by new therapies, changing care sites, and fast-paced technological innovation. As healthcare leaders adapt and prepare for more shifts in 2024, forward-thinking, data-driven approaches will be key for supporting payment integrity while capitalizing on emergent new ways to optimize patient care. For example, analytics can identify areas at highest risk for fraudulent, wasteful, or abusive spending—such as billing for non-traditional care sites—and also uncover trends in utilization that could indicate unmet needs among certain populations.

Data-driven approaches will also become increasingly important to prevent inappropriate payments as more complex specialty drugs and gene therapies emerge with million-dollar price tags. Looking forward to 2024 and beyond, payers and providers must collaborate to ensure future innovations in medical technology and treatment are billed and delivered appropriately to improve patient health while protecting members’ plan benefits.

How can payers and providers better collaborate to promote payment integrity?

When providers contract with health plans, payment integrity is becoming a subject of negotiation. In some cases, providers may be willing to accept lower reimbursement rates if the health plan agrees to relax its claim editing standards—perhaps overlooking certain coding errors, for example. However, this approach is just as bad for the provider as it is for the health plan, causing future problems with data and analytics. Instead of asking the health plan to accept a certain level of error, providers should work together with payers to ensure claims are paid as promptly and accurately as possible and resolve any issues with reimbursement structure.

Another source of friction between payers and providers is medical record retrieval, which is vital to support DRG validation and other areas of payment integrity, but too often still relies on antiquated technology such as fax. By collaborating with health information exchanges (HIEs) to enable EMR connections, health plans and providers can enable the secure exchange of electronic patient data, reducing costs for the plan and administrative hassle for the provider while protecting the member’s health information.

Additionally, how can healthcare organizations leverage analytics to better identify fraud, waste, and abuse and optimize payment integrity?

Health plans have massive amounts of claims data—it isn’t feasible for investigators to look at every claim line from every provider to determine if an inappropriate billing pattern is occurring. This is where advanced technologies such as machine learning are vital. By comparing billing patterns across providers and identifying outliers, machine learning algorithms can identify problematic behavior—for example, a physical therapist billing for 30 hours of service on a single day. This approach is very similar to techniques used by credit card companies, which will often contact their customers to confirm whether a suspicious purchase was legitimate if it seems out of the ordinary compared to the customer’s usual purchasing habits.

To maximize effectiveness, this outlier analysis approach requires data from multiple payers. A provider’s claims submitted to a single health plan may not show any aberrant trends, but when reviewing their claims across multiple payers, a suspicious billing pattern may emerge. This is where a data analytics partner that collaborates with several different payers can be vital.

As the healthcare industry continues to adopt data-driven strategies and other tech innovations, what are some common pitfalls or challenges to be aware of?

As advanced technologies such as artificial intelligence and machine learning become more prevalent in payment integrity, payers may fall into the trap of thinking that technology alone is what drives value for their organization. An effective payment integrity program requires extensive clinical and billing expertise. Technology certainly is a significant aid in the payment integrity process and helps deliver payment decisions much more rapidly, which is important, but that technology must be enabled by payment policies and rules that are created by human clinicians. Otherwise, providers may not be able to trust that payment decisions are being made appropriately.

What are some steps organizations can take to support operations, efficiencies, and patient/member care in 2024?

Our entire healthcare system continues to be hampered by siloed data, which directly impacts member care and drives up costs. When a patient switches health plans or providers, their data doesn’t come with them. In the financial services industry, your credit report contains information about all your transactions across multiple institutions, but the healthcare industry simply doesn’t have that. This quickly leads to higher costs and administrative waste as payers and providers have to re-capture the member’s health history, and more importantly, diminishes continuity of care. Payers can combat this chronic problem by building their internal expertise in healthcare interoperability, participating in HIEs, and implementing APIs to support patient access, provider access, and payer-to-payer exchange.