Hi, everyone. This is Lucas Voss with the Becker's Healthcare podcast series. Thanks so much for tuning in today. Very excited to have you. And I am excited and thrilled to be joined by Mark Johnson, senior vice president at Saris, who will talk to us about payment integrity. Very important topic. Mark, thanks so much for being here today. Thanks for having me, Lucas. Appreciate it. Mark, we'll start off with
introductions here. If you just wanna give us a quick introduction to yourself and just your your background in health care and your career so far. Absolutely. I've been with, Cirrus now for a little over five years, but my background, you know, is around thirty years experience in the health care space. I've been in patient care at the bedside, into medical billing, payment integrity, insurance. Really, I've I've led significant product improvements in
that thirty years at Cirrus. We're part of the CorVel Corporation. I've been at Blue Cross Blue Shield in Minnesota. I had a stint at UnitedHealth Group as well. My background includes patient care, payment integrity, vendor management, regulatory compliance. I've done some international operations startups as well. Educationally, I've got a bachelor's degree in physiology from the University of Minnesota and an MBA from Regis University. Go Gophers in in that case. Go Gophers. Go big
10. Yeah. Ex exactly. We'll we'll go with that. Well, again, Mark, it's it's great to have you, and this is an important topic today. I was doing research for this podcast, and and this stat just really stood out to me. There's an estimation that up to eighty percent yes. You heard that right. Eighty percent of medical bills contain errors, which is staggering.
As leaders in the payer space increasingly look to really optimize processes, we know that's happening, especially around billing and payments. What's the role of payment integrity from your perspective, and why is it so important? Yeah. Payment integrity in the payer space is incredibly important. It just ensures that claims are accurately processed and more importantly, accurately reimbursed to the providers. It helps prevent errors, fraud, waste, and abuse.
Really, this is crucial because it helps maintain financial stability, not only for the payer, but for the providers being impacted. It also enhances the trust between the payers and the providers. And, you know, lastly, it ensures that the health care dollars are being used appropriately. That's why payment integrity is so important. Yeah. It's sort of a I view it sort of as a as a foundational piece. It's really the foundation that a lot
of things stand on. And if that foundation isn't there, then there are going to be problems as you've outlined. And the process is is really key to this to this area, the process around, around everything that you've touched on. How can changing the process around payments reduce some of these numbers of errors, right, 80? And what strategies have you found beneficial? Do you have any examples that that stood out to you and some of the results that that you see that that make a difference?
Sure, Lucas. I'm I'm trying to think over thirty years, payment integrity really didn't exist thirty years ago. Right? And it's going through a lot of transition right now, a lot of growth. I can think of maybe four or five key strategies that payers might wanna contemplate. The first would be to centralize their payment integrity strategy.
Take a centralized approach that integrates your prepay editing reviews, your post pay auditing capabilities, and as well as your innovation teams, your r and d teams in order to streamline processes and try to reduce those errors, especially prepayment.
Secondly, I would say when you're thinking about artificial intelligence and machine learning, those are big buzzwords lately, really think about it as a complement to the clinical teams that you have deployed in your payment integrity space as well as your certified coders.
Utilizing AI, machine learning for real time analysis of claims, proactively identifying high risk claims, and really helping your clinicians and your coders identify, those claims quickly can significantly enhance your accuracy and as well as throughput for the teams working those claims. Third strategy, contemplate a second pass claims editing process.
A second pass vendor, second pass process, or even a final filter on claims can really help catch errors that are missed in primary editing phases. Just, again, reducing inappropriate payments from going out the door. Fourth, and this is a big one, coordination of benefits. Mhmm. We really need a strong coordination of
benefits program. You may want to consider adopting a pause and pay approach with advanced analytics again, right, to ensure you're correct payment responsibility, eligibility validation before the claims are even paid. Just reduce that overpayment from going out the door and all of the overhead associated with the pay and chase model. Lastly, quality assurance programs.
Establishing a robust QA program to conduct pre billing audits can really catch errors early and then just improve overall billing accuracy. I guess with these strategies, you know, health care payers can really enhance their payment integrity program and reduce those errors, really ultimately improving overall financial performance.
Yeah. Absolutely. And just as a as a quick follow-up to that, should this be a a holistic approach as in we're focusing on all of these strategies, we're incorporating them all, or is there one focus area from the things that you just mentioned that that, organizations should look at? I all. I would I would be looking at all of these right now. If you had to prioritize, something, I would I would try to centralize your payment integrity strategy.
You may have payers may have post pay services, prepay services, clinical utilization management services, all under different leaderships Mhmm. Or strategies. And some of those strategies may be at odds with each other. Make sure you're all aligned first. And then you then you can really start digging into solutions, vendor partners, like Cirrus or any other, technology play. Yeah. Absolutely.
Which leads me to my next point, and this was one of your your strategies or one of the pieces of that you've mentioned that are really important right now. The modernization efforts efforts that are happening in the payer space. They are all over. You've mentioned the buzzwords. Right? AI. It's it's all over the place. Again, touch on how you see technology evolving and really making an impact on reducing errors and enhancing payment integrity.
What are you looking forward to right beyond those buzzwords, and how should organizations prepare? Wow. That's it's such a big area. The technologies are just evolving so rapidly. I would say that if if you have an AI strategy, excellent. If you don't, get one quickly. Innovations such as artificial intelligence, digital payment systems, finance solutions, just embedded finance solutions are really
transforming health care payments. Mhmm. Providers themselves are starting to look at these these technologies as well to help them with their revenue cycle. So while this these technologies I mean, all of this tech play can really help automate billing processes and reduce manual errors and just improve that rev cycle for both payers and and providers. It's still going to be important to have that human touch, that clinical overview, that coder overview.
You don't want to get caught automating your your edits, automating your your solutions. Technology can help, but you shouldn't put all of your eggs in just in that baskets. You know, adopting advanced payment technologies, making sure that that cash is flowing smoothly and accurately between the payer and the provider. And I think that's that's really where you're gonna wanna be focused. Yeah. Absolutely. Well, Mark, thank you so much for sharing all of your insights here. Again, thirty years
of experience. We really appreciate you taking the time today. Thanks for being here. I appreciate it, Lucas. Thank you for the time. I I really do. Yeah. Absolutely. Thanks for sharing everything. And I'd also like to thank Suresh as well for sponsoring this episode. And you can tune in to more podcast from Becker's Healthcare by visiting our podcast page at beckershospitalreview.com.