There are a lot of reasons to start a payment integrity program: potential cost savings, operational efficiency, a taste for innovation. For Chad Roswick, senior director of Enterprise Shared Services at L.A. Care, a health plan serving the most vulnerable residents of Los Angeles County, the reason was financial stewardship. The health plan has a large Medi-Cal membership, and Chad wanted to make sure that they were properly administering state and federal funds and reducing expenses when possible.

Regardless of your reason for looking into payment integrity, Chad’s journey provides a blueprint for getting a similar project up and running in your own organization.

Creating a Roadmap for Success

When Chad set out to create a payment integrity program, he started by creating a roadmap for how it should be built. Since nothing like this existed in his organization, he was starting from scratch.

The first step on the roadmap was to design a coordination of benefits program to make sure that L.A. Care had the right eligibility for its members, and that the right primary coverage information was being used when a claim came through.

“We knew that we wanted to stack our payment integrity services and capabilities, and to begin by addressing the lowest hanging fruit, which was retrospective claims,” Chad said.

He launched a retrospective data mining initiative—implementing rule-based analytics within their system—to aid in payment recovery.

These retrospective efforts allowed Chad to demonstrate value for the payment integrity program, and he was afforded the opportunity to shift upstream in the claim payment process and incorporate a prospective editing tool that would generate savings before the claim was paid.

Winning Over Executive Skeptics

At the beginning, Chad faced two major challenges for getting buy-in from his executive team: L.A. Care had never done this before, and IT resources, from which he would need ongoing support, were constrained. It was therefore critical that he demonstrated the value that this program generated.

So that he could demonstrate that value as quickly as possible when he deployed the program, he focused first on quick-win opportunities. Once his team started to succeed with those, the conversations with the executive team got easier. Because has continued to share return on investment, he continues to have support from the executive team to scale the program and generate additional savings.

“Once we were able to demonstrate value, it didn’t take very long for us to see a shift in the way that the organization was thinking about payment integrity. In the first six months, a lot of the questions we were getting were: ‘Why do we need a payment integrity program? What value does it generate?’” Chad said. “As we stood up the program, the question became: ‘Why haven’t we always done this?’”

Provider Communication Is Critical

Although the payment integrity program was new for L.A. Care, most providers in their network were already familiar with this type of initiative. In hindsight, Chad believes that their initial communication to providers about their new initiatives was not comprehensive enough.

“If we could go back, we’d have been thoughtful about the impact on providers, and we would have been as transparent and provided as much information as possible about these claims,” he said.

They are now looking at ways to improve their communication. Examples include letting providers know when they identify that a member has other primary coverage and they are looking to deny a claim because of it, and using plain English in overpayment letters to describe what they are looking for.

“At the end of the day, providers want to be paid appropriately for the services that are rendered,” Chad said. “That is our biggest focus.”

Advice for Starting Your Own PI Program

Based on his experience setting up a payment integrity program, Chad has some lessons to pass on to others embarking on a similar path:

1. Establish a clear roadmap at the start. Timelines and priorities may shift as the program develops but starting with your end goal in mind will allow you to stick pretty closely to your original intentions.
2. Divide and prioritize the work that needs to be done. Approach the project in manageable pieces and be thoughtful about what needs to be accomplished first.
3. Use measurable results to demonstrate the value of the program. It is important to make sure you’ve established not just the current state, but also what the future will look like and the benefits it will bring. Being able to present this data is key.
4. Leadership commitment is critical. Consistent and strong leadership support is needed to allocate the resources you’ll need to grow your program.
5. It comes down to execution. Once you have the playbook, it is all about rolling up your sleeves. 

Start by Amping Up Your COB Process

Focusing your COB process on early identification of overlapping coverage to prevent incorrect payments increases efficiency and cost savings. Download our toolkit to get a step-by-step guide to moving your COB process from "pay and chase" to proactive.

To learn more about how CAQH helps health plans with coordination of benefits and payment integrity, click here.