For many health plans, care provided in the home health setting presents a dilemma.
On one hand, the home is often the final step on a member’s care journey to recovery and typically has lower costs than the inpatient or skilled nursing facility settings. Members also prefer the convenience of being at home and report higher levels of satisfaction. On the other hand, though individual claim amounts may be low, increased claim volumes mean any oversights can quickly snowball into significant financial losses. Increasingly, we also see disreputable providers using the home health setting to submit fraudulent claims.
So the question health plans must answer is, how do we ensure the payment integrity of home health claims while continuing to encourage its use as a cost effective setting?
At SCIO, we’ve been considering this question for over 10 years and seen first-hand each new challenge and reimbursement methodology emerge. During this time we’ve supported health plans strike a fair balance with providers by correcting problematic policies and developing high quality audit programs with low appeals rates.
We invite you to join us for a complimentary educational Webinar where our experts will share their thoughts and discuss best practices related to the below topics:
- Optimizing Home Health: Identifying policy gaps
- Patient-Focus: Defining “homebound” and medical necessity reviews
- Provider-Focus: Role of fraud-like SIU audits
- Future State: Trends you need to be aware of
Attendees will learn specific actions they can bring back to their organization and there will also be time set aside at the end to ask any specific questions you may have.
Nicole Cormier, LVN, CMAS, HCS-D
Senior Manager, Selections
Product Manager, Reimbursement Optimization
Fraud is what results when someone does something they shouldn’t. It’s critical to look beyond the “what” is happening and to the “who” is doing it. Identities fuel healthcare and whether it’s someone enrolling directly or through a broker; or it’s someone with a complex social network - the key to detecting fraud before it happens is understanding the risk associated with the individuals engaging with your plan.
The bottom line is identities are as complex and aggressive as the schemes they execute. Claims data is one piece of the puzzle that provides some understanding of the risk your organization is exposed to. Layering non-healthcare data sources, linking and relationship analytics, and identity domain expertise allows you to get the full view.
Join this webinar to learn strategies that help:
- Organizations evaluate and leverage identity-based data and analytics.
- Identify suspect enrollment early.
- Build out complex social networks to help identify top cases and allocate SIU resources more effectively.
- Avoid losing millions while also adhering to Federal compliance standards.