The Road to Implementation: Building Bridges with Clinical Excellence

The Road to Implementation: Building Bridges with Clinical Excellence

What is clinical excellence? To XSOLIS Director, Clinical Practice, Michelle Wyatt, DNP, MSN, RN, IQCI, CPHM, it means “to excel in clinical aspects of patient care.” And the Clinical Excellence team at XSOLIS strives to help their clients achieve that goal by stripping away the administrative layer that keeps them from working at the top of their license. Wyatt and her team work with UR experts across the nation to ensure the CORTEX go-live process is as seamless as possible, while always keeping the patient in focus.

Source: The Road to Implementation: Building Bridges with Clinical Excellence

Fresh Eyes, New Approach – Conversation with HealthPartners

Fresh Eyes, New Approach – Conversation with HealthPartners

Earlier this week, leaders from HealthPartners joined XSOLIS on a webinar covering their recent implementation of CORTEX and how their organization is bringing fresh perspective to utilization management. Bror Herrick, System Director of Utilization Management, and Melissa Seleski, Program Manager for UM, sat down with Cameron Bowman and Carol Schultz of XSOLIS to discuss recent changes and what they mean for their organization. The conversation covered three major themes:

Source: Fresh Eyes, New Approach – Conversation with HealthPartners

XSOLIS Named a Finalist in the Fierce Innovation Awards – Healthcare Edition 2020

XSOLIS Named a Finalist in the Fierce Innovation Awards – Healthcare Edition 2020

XSOLIS announced today that it has been selected as a finalist in the Fierce Innovation Awards – Healthcare Edition 2020, a peer reviewed awards program from the publisher of Fierce Healthcare, produced by Questex.  The competition highlights companies that demonstrated innovative solutions that have had the greatest potential to save money, engage patients, or revolutionize the industry over the past 12 months. XSOLIS was recognized as a finalist in the category of Financial/Operational Solutions.

Source: XSOLIS Named a Finalist in the Fierce Innovation Awards – Healthcare Edition 2020

How can the SIU find value with A.I. for fraud detection?

In partnership with NHCAA, ClarisHealth is hosting a live, educational webinar on Tuesday, August 11 to talk with health plan fraud teams about how advanced technology – specifically solutions that employ artificial intelligence – can offer value to the SIU. 

We sat down with the experts who will be presenting the webinar – Mark Isbitts, vice president of program integrity for ClarisHealth, and Kyle Cheek, the director at the Center for Applied Analytics and Clinical Associate Professor of Information and Decision Sciences at the College of Business Administration at The University of Illinois-Chicago – to get a quick preview of the session. 

LIVE Webinar Tuesday, August 11 – 1 pm CDT | 2 pm EDT 

Read the Transcript

AB: In partnership with NHCAA, ClarisHealth is hosting a live, educational webinar on Tuesday, August 11 to talk with health plan fraud teams about how advanced technology – specifically solutions that employ artificial intelligence – can offer value to the SIU. 

We sat down with the experts who will be presenting the webinar – Mark Isbitts, vice president of program integrity for ClarisHealth, and Kyle Cheek, the director at the Center for Applied Analytics and Clinical Associate Professor of Information and Decision Sciences at the College of Business Administration at The University of Illinois-Chicago – to get a quick preview of the session. 

Both Mark and Kyle have worked with and in health plan fraud organizations for years. Mark provided insights into three major challenges facing SIU teams: 

04:17-04:29 Mark “The bigger issue is they need better leads. They need to reduce the false positives and get more accuracy around what they’re facing.” 

05:13-05:30 Mark “The whole process of … or a true trend.” 

08:33-08:54 Mark “Classic example is … not getting any more resources.” 

10:54-11:05 Mark “Only addressing the big dollar cases. And that’s really at the heart of it. Spending a lot of time without getting much in return.” -11:10 “That’s why getting the false positives down is so critical.” 

AB: With these seemingly insurmountable challenges of too many false positives, not enough resources to dedicate to hitting escalating targets, and a lot of manual processes to connect the dots on leads and weave together a workflow, investigators have an idea of how their day-to-day could improve. According to Mark, it’s about prioritizing the data and presenting it in context: 

12:00-12:28 Mark “Ideally, they want to be told what to look for: here’s a provider, here’s why they’re abnormal, here’s how big a deal it is, here’s how sure it is a real case.”  

AB: SIU teams are concerned about providing value and proving that value, but with no way to trend the data, they might be overlooking potentially big cases: 

15:05-15:35 Mark “If someone’s really good at gaming the system, they’ll just be upcoding from a level 3 to a level 4 office visit every other patient. What’s that, $50? Not enough to notice over a short period of time, but it really adds up over a year.”         

AB: And, as Kyle reminds us, it’s not just ROI that’s at risk when investigators are making value decisions on whether or not to pursue a case. 

22:20-22:59 Kyle “Health insurance company has a counter-balancing interest in maintaining goodwill in its provider network. Fraud mostly driven from the provider side. SIU challenge is not only do they have to build a case strong enough for law enforcement but strong enough to sell internally and consider how it affects other business units.” 

AB: Healthcare data – both in terms of quality and quantity – has traditionally been a huge hurdle in fraud teams’ abilities to take advantage of advanced technology, which sets it apart from other industries’ advances in nearly hands-off fraud detection. 

23:48-24:05 Mark “Healthcare fraud is so grey where something like banking fraud is black and white. Those grey areas are why you need different detection systems than what they have.” 

26:00-26:22 Kyle “It’s just a function of the way the business works that … If CMS would just put a checkbox on the 1500 form that says is this claim fraud, yes or no, that would make things a lot easier, but it doesn’t exist.” 

26:50-27:23 Kyle “It’s the difference between being able to measure the accuracy of your models and not being able to directly measure … Healthcare falls as far on that spectrum as they can be towards not having labels on the data and having to do unsupervised analysis and really being an exercise of feeling around in the dark as best as possible without having traditional tools to measure analytic performance by.” 

AB: Because healthcare data presents so many challenges with its complexity and lack of consistencyadvanced technology offers distinct advantages, but A.I. is easily misunderstoodWith his expertise in data science, Kyle has some theories as to why. 

32:05-32:33 Kyle “Everyone focuses on the “I” and I think the emphasis should be on the “A.” The key qualifier is artificial. We’re trying to build processes that emulate something, and the thing we’re trying to emulate is intelligence. And most of us don’t have a good definition of intelligence – cognitive scientists don’t have a good definition of intelligence.” 

AB: And it’s not just common definitions that are lacking. The way applications of A.I. work, they’re really good at producing superior results, but they can resist simplistic explanations.  

36:25- Kyle “Where we think of traditional models, we tend to think of those in a linear context. It’s easy to say, ‘If a provider’s use of a certain procedure goes up, the probability they’re committing fraud goes up. In the case of neural nets – of multi-layered, sequential, recursive, iterative processes – we can’t simplify the causal links that way.” 

41:21-41:35 Kyle “It’s pretty easy to make improvements in the output of the analytic engine, but it’s hard to do so in a way that maintains the transparency in why the result was produced.” 

AB: How can models for healthcare fraud detection that take advantage of A.I. overcome the challenges with healthcare data, avoid provider abrasion and offer explainability for investigators so they can focus on their best work, trust the results and prove value for the SIU? Mark and Kyle will be discussing these hot topics and showing some real-world examples in this interactive session. 

Please sign up today to attend the live, educational webinar Demystifying A.I. for Healthcare Fraud Detection: Finding Value for the SIU on Tuesday, August 11 at 1 pm CDT. Find the registration link in the description below. 



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Source: How can the SIU find value with A.I. for fraud detection?

Health Plans Launch Innovative Solutions to Respond to Mental Health Crisis

Health Plans Launch Innovative Solutions to Respond to Mental Health Crisis

Transparent data sharing supports seamless care coordination, relevant outreach that mitigates effects of chronic conditions. 

The novel coronavirus pandemic continues its near-perfect record as a harsh but effective teacher for the healthcare industry as it efficiently evolves systemic weaknesses into full-blown crises. Patient and procedure volume-based reimbursement structures? Check. Primary care access? Check. Healthcare coverage? Check. Now we can add the mental health status of Americans to that list. But, even with these issues, the ability to steer through the challenges and find our way to an appropriate solution is still within reach. And payers, with their increasing focus on whole-person care, are particularly suited to drive these changes.  

How can health plans promote improved access and outcomes in mental health while controlling costs associated with this expensive chronic condition during the pandemic and beyond? And what are the implications to health plan payment integrity operations? Let’s explore the landscape and potential solutions. 

Challenges: Access and Expense 

It’s estimated that 1 in 5 Americans suffer from mental health issues. It’s a problem that’s already been increasing in severity across our population, especially among teens and young adults. But with the onset of the pandemic, there are signs that figure may be increasing dramatically. 

Increased isolation, grief, job losses, pressures from juggling home/work/childcare responsibilities, extended uncertainty and more are creating and worsening anxiety and depressive disorders. And, among frontline healthcare workers and other essential employees, in particular, there are concerns with potential long-term PTSD-akin effects. Experts predict an associated increase in suicides, overdose deaths and substance use disorders as well. 

Why are these rising cases such a concern? There are two big perennial challenges associated with mental healthcare.  

Limited access to care

Without proper intervention and maintenance, there is risk of situational mental health issues becoming chronic and existing mental health conditions becoming increasingly severe. But while 20% of Americans experience mental illness, historically less than half receive treatment. This limited access to appropriate care has a variety of causes. While there are cultural barriers – concern about perceived stigma, for instance – structural barriers are just as restrictive.  

At least 60% of U.S. counties don’t have a single practicing psychiatrist, so even for those patients covered by insurance, access is an issue. They struggle to find in-network mental health providers that will take their insurance. One study found that these patients with commercial insurance were up to 15% more likely to receive out-of-network care than other chronic disease patients, and their cost burden was almost 4 times higher. 

And, for those who have managed to get treatment, the pandemic has limited their in-person visits and put their providers in a precarious financial position. Already vastly underfunded, fragmented and difficult to access, mental health providers have been just as impacted financially as other healthcare providers. But because relief funding is largely based on Medicare rates, rather than Medicaid, community behavioral health centers were less likely to pursue and receive support.  

Mental health and addiction providers estimate they will lose $38.5 billion in revenue in 2020, and more than 60% of providers had already been forced to close at least one program before the end of April. Close to half of mental health and addiction providers report their chances of survival at 6 months or less in the current fiscal climate, minimizing their ability to act as a safety net when they are needed most.   

Expensive to manage

Mental health conditions negatively impact quality of life and economic productivity, which are grave enough consequences. But in addition to the healthcare industry lacking sufficient mental health resources, it is also one of the more expensive chronic conditions to manage. In 2019, the U.S. spent over $225 billion on mental health services, or 5.5% of total healthcare spending, and that dollar amount has increased over 50% in the last 10 years.  

Direct spending on mental health services doesn’t paint the full picture. Mental illness is disproportionately associated with physical chronic conditions as well – cardiac, pulmonary and obesity comorbidities. In fact, depression quadruples the risk of a heart attack. And taken together, these issues create a much bigger impact. According to the CDC, 90% of national healthcare spending goes towards managing chronic conditions and mental health.   

Approximately 75% of those with severe mental illness (SMI) have at least one chronic physical ailment, and the number increases among vulnerable populations. One study of Medicare beneficiaries found 12.7% of spending was associated with mental health disorders, but mental health services only made up 4.2%. In fact, patients with an SMI reflected a 37% increase in physical healthcare costs, and an 18.4% increase for those with other common mental health disorders.  

Opportunities: Telehealth and Whole-Person Care  

Even with these systemic challenges associated with mental healthcare, promising signs have emerged that hold the potential to mitigate their effects, including rapid adoption of telehealth and payers increasingly focused on whole-person care.  

Accelerated virtual care adoption 

Telehealth use already found its niche in behavioral healthcare, especially in underserved areas. But with the stay-at-home orders, telehealth claim lines increased more than 8,335% from April 2019 to April 2020. Mental healthcare was a big driver of those visits, but chronic condition management made big gains in virtual care adoption as well.  

Teletherapy offers distinct advantages for mental health patients, not the least of which is extending access to mental health providers when availability or convenience is an issue. It also eliminates the need for travelling to an appointment, allows for a familiar environment and may even mitigate concerns of stigma. Mental health providers, too, see benefits by gaining insights into the home environment and allowing patients to more easily maintain valuable therapeutic visits. 

Even though many patients had little to no experience with telemedicine or other forms of virtual care, most have been pleased with the encounters and want to see it continue indefinitely. And, in the same way payers have seen success with virtual care for monitoring and managing physical chronic conditions – and creating patient trust in the process – there is reason to expect similar results with mental health conditions. 

Increasing focus on whole-person care  

Health plan models are increasingly centered around improving the delivery of person-centered care. How can you treat the whole person and engage provider, patient and other stakeholders after the encounter? Two different models of coordinated care for better integrating mental health are common.  

Co-location of services – where mental health and primary care providers physically exist in the same place – offer economies of scale, efficiency and improved outcomes that benefit health plans. Looser collaboration agreements don’t require a provider organization to deliver the full array of services, provided they work closely with others across the service delivery ecosystem to ensure coordinated access to care, but does necessitate a technology infrastructure that supports true data interoperability. 

For health plans, both models see the full array of services – for mental health and physical healthcare – covered under a single agreement with a goal of positively impacting utilization and health outcomes. And new clarity on privacy regulations makes it more straightforward for providers to coordinate care for those patients suffering through a crisis. 

Innovative approaches to coordinated care promise to unlock value for payers, providers and consumers by supporting alternative reimbursement models; offering leeway on care modalities to include telehealth, remote patient monitoring technologies, and care management home visits; and providing real-time care integration. Many health plans are relying on integrative technology solutions as a backbone to power a seamless patient care experience, and these benefits extend to behavioral health.  

Advanced Technology Enables Relevant and Sustainable Solutions 

While the challenges – and opportunities – are significant, health plans don’t have to pioneer entirely new programs in order to improve systems for mental healthcare maintenance and intervention. Engaging members and providers via current advanced technology initiatives can strategically extend this function. 

Member engagement 

A new poll confirmed what we already feel to be true as consumers: the healthcare industry is simply too complex to navigate effectively. Respondents overwhelmingly cited every aspect of healthcare – care access, management, and payment – as needing to be streamlined and simplified. “They want health plans and providers to end the fragmentation, simplify the experience, and deliver a fully connected encounter that makes healthcare as seamless as any other online endeavor.”  

Arguably, the system proves to be even more unnecessarily opaque for those experiencing mental health issues and their support system. And those with mental health disorders are at higher risk during the pandemic. Many health plans already prioritize seamless member engagement opportunities, supported by modern communication modalities. But, as we wrote in a previous article, consumers want to hear from their health plans more, especially with relevant information. One payer program of this type is already seeing the benefits. 

Additionally, more advanced solutions like population health management platforms, such as that offered through Pareo, allow you to proactively assess disease risk among your membership. Taking this opportunity to reach out to members about their telehealth options, the importance of medication adherence, information about prescription assistance, wellness options, chronic disease management, checking in with a primary care provider, how to better protect themselves from COVID-19 and more promises to yield significant dividends.  

Provider engagement 

Many behavioral health providers and facilities still receive most of their revenue from fee-for-service reimbursement, but from there member experience can unravel. Some payers will not give reimbursement checks to a facility directly, but rather to the plan member. This can create abrasion between the patient and provider as well as the provider and the payer, but that risk can be mitigated through strategies like prospective cost avoidance and coordination of benefits.  

However, in order for mental health providers to shift revenue management strategies, health plans need to be in a place where they can support prepay. Pareo is a seamless payment integrity solution that can power retrospective and prospective claims recovery. It does this in part through automated workflows and by housing relevant medical claims data, enabling plans to hold up their end of prospective cost avoidance.  

Related to mutually beneficial payment structures, a survey conducted in March 2020 indicated 74% of primary care organizations and 61% of behavioral health organizations participate in some form of value-based reimbursement. But, only 16% of those organizations have 20% or more of their revenue in such an agreement. With health plans looking to accelerate adoption of alternate payment models, it’s important to keep in mind what’s essential to their acceptance and ultimate success. 

Extending clinical data interoperability, integrated workflows, proactively identifying gaps in care, and real-time metrics are key components of modern value-based contracts. When health plans better engage with mental health providers, those providers are empowered to better support members. And transparent data sharing – like that supported by the integrative platform Pareo – extends health plans’ abilities to do exactly that.  

Pareo Provider is a seamless technology platform for real-time engagement with providers, including specialty providers. Not only for the purposes of payment integrity – though Pareo effortlessly accommodates complex reimbursement contracts and supports two-way communication on claims. But also new information on virtual care allowances, sharing quality metrics, getting credit for SDOH assessments and more – without increasing the provider or payer administrative burden.  

Pareo is a Single-source Solution for Payment Integrity Operations

Understanding trends in behavioral health management is vital to health plans, and payment integrity teams must take note of the implication of mental healthcare utilization on their operations. With only half of those who suffer from mental health conditions receiving care, and many members eligible for care struggling to find access to providers, complexities abound. Further, many mental health providers and facilities are using outdated payment models, because before the Affordable Care Act, mental health was often not a covered health insurance benefit.  

Pareo is a single-source payment integrity solution that can integrate with myriad data systems to power even the most nuanced retrospective and prospective claims recovery efforts. Within Pareo, features that support provider engagement, population health management and prepay can facilitate (and automate) facets of behavioral health claims management to create a better experience for payers, providers and most importantly – patients. 


Talk to ClarisHealth about how Pareo® comprehensive payment integrity technology is helping health plans deliver on their most advanced digital strategies.

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Source: Health Plans Launch Innovative Solutions to Respond to Mental Health Crisis