Medicare Advantage plans can get ahead with better data and claims member management
Discovery Health Partners
November 8, 2018
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This post is sponsored by Discovery Health Partners.

As Medicare Advantage plans see spiking growth and an influx of new players, they need to optimize in all areas – especially member eligibility management and coordination of benefits. Focusing on these areas can help plans operate more efficiently and improve overall financial performance. SmartBrief spoke with Lyndsay Deckert, director of solution strategy for Discovery Health Partners, on how plans can improve their coordination of benefits.

Lyndsay Deckert
Lyndsay Deckert

As MA plans grow, what are some of the things they are struggling with in relation to claims and premiums?

As health plans continue to pursue Medicare Advantage growth goals, they increasingly need to proactively manage the revenue and costs associated with members in order to maximize the health plan’s financial performance and their service to members.

At the root of this challenge is the accuracy of member information that impacts premiums and claims payments for each member. Inaccuracies and gaps can result in significant impacts to a plan’s bottom line. As plans continue to focus on growth, they should incorporate best practices to manage member eligibility, claims payments and premiums to protect their financial position in support of their existing members as well as their expansion goals.  

How can they ensure they are recouping the right premium amounts from CMS?

Member eligibility information and special statuses or “flags” on the Monthly Membership Report can significantly impact the premium amount a health plan receives from CMS. In particular, flags for Medicare secondary payer, end-stage renal disease, and hospice can dramatically impact the way a plan is paid by CMS. Understanding the impact, monitoring changes, working with all stakeholders in validating accuracy and updating these data points can optimize the plan’s premium opportunity.

How much do payers stand to benefit financially and operationally by validating eligibility information and improving coordination of benefits?

With better access to more accurate member eligibility information, health plans can also recover millions in incorrectly paid claims and use this information to avoid paying claims incorrectly going forward. This results in huge impacts to a health plan’s bottom line. For example, we have helped our clients restore more than $300 million dollars in underpaid premiums by helping them validate and update member information.

How can analytics and big data help with these tasks?

Because there are so many factors that can impact how claims should be paid, health plans are challenged to access, process and leverage all the information that can help them protect their bottom line. Of course, data is only meaningful if health plans can use the information to take action. Health plans should look for a technology-first approach that connects new data and analytic insights with strategies to engage with and apply member information.  

When working with a partner, how can health plans ensure their data will be safe and secure?

We understand that the healthcare industry is under significant pressure to adhere to compliance requirements for patient privacy and data protection. Consequently, health plans require their vendors and partners to demonstrate an ever-increasing commitment to patient and member data privacy and protection. Here at Discovery Health Partners, we have stepped up to meet this demand with the achievement of HITRUST CSF® certification for our core technologies.

Discovery Health Partners is an industry leader in helping healthcare payers solve payment integrity challenges to improve financial and member outcomes. Learn more at www.discoveryhealthpartners.com.