[00:00:00] Stacey Richter: Episode 498. "The Payment Integrity Arms Race RCM—(Revenue Cycle Management) and Plan Sponsors." Today I speak with Mark Noel.
This episode is part of the "Inches Are All Around Us" series because yeah, you'll see why fast enough. So last week or two weeks ago, if you listened to that episode about clearinghouses with Zack Kanter, you may or may not recall, and if you didn't listen to that episode, no worries. Just go back and soak it in when you have a sec.
But in that episode about clearinghouses, I said something about how self-insured employers are bringing a knife to a gunfight if they do not have real programmatic integrated payment integrity programs.
Because an arms race is afoot whether or not the self-insured employer, or other plan sponsors recognize they're in one. The arms race, by the way, is with revenue cycle management (RCM).
Here's a quotable quote that my guest today, Mark Noel says in the conversation that follows, spoiler alert, I suppose, but around the 27-minute mark or something he says and some light editing by me, but he says, It's an arms race. It's a tug of war. It's a zero sum game.
Because you have the RCM folks on the front trying to maximize revenue, and you have the self-insured employers and plan sponsors on the backend trying to pay as little as they need to. And so it is imperative that the payment integrity vendor is keeping their policies up to date as of the minute, because these things change all the time, and the rev cycle management side is gonna be up to date.
So right, on one side you have RCM. The RCM industry. A $140 billion behemoth by the way, that is already larger than the US auto industry and growing five times faster. These RCM vendors are using programmatic clearinghouses as discussed 2 weeks ago. Plus, they're ever more sophisticated with automatic tools to maximize every cent of revenue they can squeeze out of a claim. That is their job.
On the other side sits the self-insured employer, often relying on less sophisticated processes and or maybe even vendors who are effectively phoning it in. Because they have an incentive to not do a great job here because right, perverse incentives. Who is surprised? No one is surprised.
Listen to the show with Justin Leader on the mystery of the weekly claims wire.
So prepayment integrity is what I talk about today with Mark Noel, my aforementioned guest today. Mark, is from ClaimInsight who I do need to thank, by the way, I need to thank ClaimInsight for donating some financial support to help Relentless Health Value here, cover expenses.
But here's gonna be the three prepayment integrity revelations that Mark Noel brings up in the conversation that follows.
Revelation 1: The small claim goldmine, I'm gonna call it. We often obsess over the for good reason, don't get me wrong, but we obsess over the million dollar babies or the cancer case, right? These high cost claimants, but 80% of claims volume is actually small claims, right? Not 80% of the spend, but 80% of the volume.
Overpaying or double billing on thousands of like $200 claims adds up to millions of dollars in wasteful inches very quickly. Stan Schwartz talked about this on an earlier episode from a little bit of a different angle, but same result applies.
Here's Revelation 2: That we talk at some length about in the conversation that follows. The conflict of interest trap. It is a fundamental business mistake to hire the same company to do the work as you do to check the work.
Asking a TPA or an ASO to report on their own errors is like asking for a tax penalty audit from the same person who filed your return, right? It is just an inherent conflict of interest. It's almost not fair to either party. Just yeah. So that was Revelation 2.
Revelation 3 is the perverse incentives of many things, but one of them is shared savings that we talk about today. Many carrier contracts allow them to earn shared savings on the backend for fixing errors that they didn't catch on the front end, right?
So this means that they actually have a perverse incentive to let errors through initially so that they can get paid a second time to recover money that they should never have spent in the first place.
Maybe I'm saying the quiet part out loud now. I do not know, but in the light of day, these revelations are kind of stark and fairly unimpeachable, and this matters because ultimately prepayment integrity, maybe just payment integrity in general, isn't just a financial issue for the plan. It is a bulwark for members. We live in a world where 41% of Americans have medical debt.
Ensuring that a claim isn't wrongly expensive, which the members paying a part of here in a lot of cases. It’s a fiduciary and probably moral imperative, just like has been said 50,000 times on this podcast. Plan sponsors must demand unconflicted expertise at the table, transparency, trust that can be validated.
Mark Noel, my guest today has worked in payment integrity for about 25 years, both on the health plan and on the TPA side, as well as working with self-insured employers. Mark is CEO over at ClaimInsight.
My name is Stacey Richter, and the show today is sponsored by Aventria Health Group with an assist from ClaimInsight.
Mark Noel, welcome to Relentless Health Value.
[00:05:48] Mark Noel: I appreciate it and glad to be here.
[00:05:50] Stacey Richter: What we're gonna talk about today is Revelations. I'm thinking three that are buried in plan, sponsor spend which you see clearly, but maybe are a big reveal for others.
So let's take this from the top. One thing that you said that was a revelation for me at least, was the huge amount of savings, like millions upon millions of dollars in some cases, that you are able to recover from claims that are under $500. Do you wanna talk about that?
[00:06:20] Mark Noel: Absolutely. Across the industry, generally 80% of claim volume by claim numbers is in what we call professional claims. So going to the doctor's office, you know, getting your blood drawn, all of those type of things. So smaller claims.
20% of claim volume is on surgeries, you know, inpatient stays, all those larger claims. So when we think about claim volume, 80% comes from the smaller claims, 20% from the larger claims. However, from a spend perspective, it's 50/50, if not, you know, 60/40 in terms of those higher dollar claims being more spend.
So when I talk to payers, prospects, clients, a lot of them focus their payment integrity resources on those higher dollar claims. And there's a lot that they don't focus on on the smaller dollar claims. And so yeah, 80, 90% of those claims are just either not being touched or not being touched like they should be.
And so what we see and what I've seen for 20 years is the savings that's generated on those smaller dollar claims is meaningful. And even though it's $2 here, $5 there, $10 there, that really adds up. And again, it goes back to the, since 80% of the claims are that size, that's really important.
So when we're talking about savings that we find with clients, yeah, the vast majority is on those lower end claims because they're not being focused on.
I think that's the nugget there.
[00:07:46] Stacey Richter: Dr. Stan Schwartz said something, he was on the pod from Zero Health on an earlier show where he is like, if we just move like metabolic lab tests from one vendor who's charging a hundred bucks to another vendor who's charging six, that over the course of a year equals a high cost claimant. Like you can save 50, $60,000. So, you know, just all these little, these little things add up.
When you go and you talk to a plan sponsor, so you walk in the door to a plan sponsor or even a TPA, how does this come up? Like when you say, by the way, there's tens, hundreds, millions of dollars that are being squandered, five bucks at a time. What's the typical reaction?
[00:08:28] Mark Noel: Yeah, it, it's funny they understand that, but they've just never put the time, energy, and resources to fixing it because they think, they don't think of it in terms of being a big number.
And so again, been doing this all these years, every single time we've ever done what we call an opportunity analysis. Every single time it pops out and it's the first thing we talk about is just so you know, the majority of your claims are five bucks, $10, that's where your savings is coming from, and we just show it in real data.
[00:08:57] Stacey Richter: And now you'd have to find these things right away because it's not like you can go back and have a big fight over $4 like that just, the math is never gonna work out relative to the logistics.
So how are you, what's the recommended pathway here? Like you'd have to find these things prepayment.
[00:09:15] Mark Noel: That's exactly right. Yeah, and that's where, you know, the industry is going there. It's mostly there with the large insurers. It's getting there with a lot of TPAs.
There are still a lot of self-insured employers who either aren't educated enough yet, or frankly aren't big enough to push their TPA to go there. But it's some of the things that we are working on and marketing on, honestly, because it needs to be prepayment for those small dollars to your point, because if you're finding those after the fact, you're not chasing $5 and $10.
[00:09:45] Stacey Richter: Now you said something interesting, you said pushing the TPA to go there. So what I'm understanding is you work with self-insured entities who have a TPA who works with you or a prepayment integrity vendor like this is not something that you're gonna hook up yourself to and a self-insured employer's data feed independently.
[00:10:07] Mark Noel: That's right. Yeah. In order to do this prepayment, you need to be connected to the processor or the administrator, which in that case is the TPA. And so, yeah, I know it's one of the other revelations we're gonna get into. But yes, there are TPAs, most TPAs are doing some but not all.
[00:10:22] Stacey Richter: Give me some examples here of like, okay, $2 here, $5 there. Are there certain types of things, are there usual suspects?
[00:10:31] Mark Noel: One of the best examples is vaccines, vaccinations. So if you think back to the COVID shot that everyone was getting, you know, for a while there. There's the vaccination and there's the administration of the vaccination. And so I'm not a clinical expert by any means, but there are rules out there that say you can charge for the vaccination, but the administration of it's free.
But you'll see all day long that providers are charging for both. And so that's an easy example of one that gets caught all the time and it's like $5. But again, if you have a provider who continues to do that, that $5 times a thousand claims or 10,000 claims is real money.
[00:11:09] Stacey Richter: We have a show in our "The Inches Are All Around Us" series that this is a part of with Stedi, that's a clearinghouse, who was just talking about one of the issues here being for everybody, honestly, that because the clearinghouses aren't programmatic a lot of times or they're slow, that you know, you could be a physician, you could be an RCM company even, and I'm giving them the benefited doubt that they are in the accuracy business, who accidentally double bills something or unbundle a bundle or just does something that is not according to the rules.
And it won't get caught until after the bill gets paid. We kind of have a whole, because the transactions are not efficient, it leaves room for errors being made even, you know, wholeheartedly. It's just a mistake.
[00:12:03] Mark Noel: That's exactly right. And there's another example kind of along those same lines where there are policies and edits out there that say, you know, you can't have these two things on the same day, or you can't bill these things out of order. But they get built out of order all the time. Right.
And so unless you're using someone like us that kind of stores all past history, and so every time a new claim comes in, it kind of puts it back together, if you will. Then you're not gonna catch those things and say, ah, you bill this out of order, you can't do this. And I'm gonna now deny, you know, the earlier one as well. That type of stuff.
[00:12:35] Stacey Richter: Right. And that is because of some clinical pathway or something like that.
[00:12:39] Mark Noel: That's exactly right.
[00:13:42] Stacey Richter: So let's move into the second revelation, which has been foreshadowed, the whole idea that some TPAs are not really doing a prepay analysis.
Maybe they say they are even, I mean, some probably aren't and aren't saying that they are. And there are some that are saying they are, but sort of aren't. And as we just discussed, this doing prepay payment integrity kind of has to happen at the TPA level, just from a data standpoint at this time.
What do I need to know about this?
[00:14:15] Mark Noel: Yeah, it, it is a problem. And so here's what we see kind of holistically.
So obviously the, the largest TPAs are part of large insurance companies. They're an arm of the large insurance companies. We know those large insurance companies are doing prepay editing on their own claims, meaning the claims that they're fully at risk for, right? They're doing those every day because those dollars that they save flow right back into their coffers.
When their TPA arm is looking at claims, they're not responsible for those dollars. They are essentially being paid a fee to administer those claims.
And so they're less incented to edit those. And I'm not saying there's, you know, nefarious reasons for them not to edit these, but I think it just takes a different path. It's not a focus.
And what some of them have done is turned that into a profit center. And they get paid for doing editing on those claims in different ways, whether that's keeping a piece of the savings that's found perhaps, or charging their ASO clients an additional fee to do editing. They do it that way.
But what we see is the level of prepay editing that's done on those claims that go for their TPA is absolutely not at the same level as we see on their fully insured book.
[[00:15:33] Stacey Richter: And I'm not sure how relevant this is to prepayment review, but this kinda wowed me, so, you're welcome. Did you see the whole thing about at least one of the big ASOs and their itemized bill exclusion lists?
Yeah, so this big ASO had contracts with 978 health systems, many big ones, mind you, that forbid it, forbid this ASO from doing itemized bill review.
As Chris Deacon put it on a post on LinkedIn, "Nothing says rigorous oversight like agreeing not to look". So yeah, what Mark just said.]]
Just dissecting that for a sec because you said a couple of very interesting things there.
One of them, self-insured employers are responsible for their own dollars. They are self-insured. So any dollars that gets spent that come out of the coffers of a self-insured employer come out of the coffers of a self-insured employer. It's their money.
Therefore, if there is a TPA, they are administrative services only they are being paid to administer. It's not actually their money that they are paying.
Speaking just simply from a financial, risk standpoint, you know, those are the financial incentives. There's a little bit less there. And so that's one aspect of what you're saying.
But on the back end there, and there was a show with Justin Leader called "The Mystery of the Weekly Claims Wire", where we talked a lot about exactly what you just mentioned, if there's any sort of shared savings incentives.
And Justin Leader actually wrote a LinkedIn post about the whole shared savings that if you're getting paid to pay and chase. Or you're getting paid shared savings on the backend, then your incentive is to let these, I mean, I'm just speaking financially now, right? Like and just saying it out loud, right?
Like your incentive is to let these go through so that you can find them on the backend.
[00:17:25] Mark Noel: That's exactly right. And there, yeah, there are many cases out there that you can see that, where they've done just that and it's, I let the claim go through and then I found the error I should have found.
And now that I found it, I'm gonna charge you 30% of the savings that I generated from finding it. That's absolutely right. It needs to stop. Yeah.
[00:17:46] Stacey Richter: Yeah. And I have just foreshadowed the third revelation here, which is just think about what the financial incentives are for the TPA. There's multiple, there's kind of a neutral incentive to find mistakes, prepayment. But then there's a bit of an incentive to not find them oddly.
[00:18:08] Mark Noel: Yeah. And even on the prepay side though, the market has gone toward knowing that TPAs are incented by dollars. Even on the prepay side, there is a major shared savings model around the vendor paying them a portion back of what they find and what they, you know, what they're keeping for revenue.
So again, it's, it's less my model. I'm out there trying to work with these folks to make sure their claims are paid appropriately. And that's where I think taking the approach of being on the side of the self-insured employer helps that a lot. You've just gotta get the TPAs to come around and truly want to partner with and help their ASO clients not just try to make more money. That's exactly right.
So it's the other point I wanted to make on the this third point, which is, yeah, exactly what you're making. Because the TPA is getting paid a percentage of savings, it's in their best interest to find more savings.
And, and what I mean by that is when I go to an insurance company who's fully insured and I'm working with them to set up my payment integrity program. I go through with them the, the list of policies that they can turn on or, or not, right? And we go through all of them and they, they say yes, no, yes/no. Right?
In the TPA world that doesn't happen as much. It's more go turn on all these policies and you can create more savings. Now, to me, they, they worry less about the abrasion that may come out of that on the backend, because when you start turning on edits and policies, the providers feel that and they react to that and they will start, you know, barking about, “Hey, this, you can't do this in this case. Right?”
And so it becomes more of a reactionary, they'll turn things off as the providers bark about it versus doing what I think should be done, which is at the start talking with your client about what they're willing to turn on and make the program work for them, not just be financially incented, I think is the point.
[00:20:05] Stacey Richter: What you're talking about there is that there is a sweet spot. We have a Goldilocks even relative to, you know, prepayment integrity, ie, this is what I'm understanding you're saying that you can walk in the door, turn on absolutely everything. In other words, catch everything. Make a net with a very fine mesh and go drag it in the river. Right?
Like you're gonna pick up small fish and you're gonna pick up large pieces of garbage, with that net. Now all of a sudden you've created a ton of friction.
[00:20:39] Mark Noel: Yeah. Or it could be in an area that's very sensitive for clients. Right? It could be in an area of cancer treatments or something like that. That's sure that edit is appropriate, but do you want to be denying cancer treatments for someone who has cancer, right. It's that type of stuff.
Some clients will say, agree that that's a real edit, but you know what? We have a policy internally that says we will never deny cancer treatments. You know that type of a point.
If you don't have that conversation with the TPA and the group and they don't have that option to say that, and that's where I think it's important.
[00:21:13] Stacey Richter: Got it. So we've got some nuances here. Just kind of recapping where we are in this conversation.
We have gotten through three revelations. The first one is just how much money is buried in these small claims, and it kind of makes sense when you think about it exactly like you just said, you've got 80%, you know, it's the 80/20 rule. Even if the spend is 50/50, you got 80% of your claims that are flying through these little claims, but there's a huge volume of them. So that's the exactly first thing.
The second one is there are TPAs who may not be doing prepay analysis. They may be saying they're doing it, they may not be throwing their backs into it.
And then TPAs get paid a bunch of different ways here if they are incented on the backend to collect shared savings, or if they're not incented on the front end, then you wind up with this conflict of interest and perverse incentive.
[00:22:09] Mark Noel: Absolutely. That's exactly right.
[00:22:10] Stacey Richter: Okay, so now what we're talking about is like, all right. Let's just say that I, as a self-insured employer, as a plan sponsor, have decided I'm gonna be looking into this prepayment integrity thing. Like, one of the things that I'm understanding relative to the data, and you alluded to this earlier, that it's not something that you can go hooking up with an individual self-insured employer to easily, that it has to kind of get hooked up at the TPA level.
So, you wind up, you'll work with a TPA, and then you go around to all of the self-insured employers who are clients of that TPA. And you say like, “Hey, you should use us as an option.”
And then you have some conversations with them. Like for example, let's Goldilocks, you're, you said edits and policies like you determine what you wanna be turning on here.
What else is part of that conversation like? So if I'm just thinking about what a best practice looks like there, one is what's Goldilocks relative to what you turn on? What, what are some other things?
[00:23:05] Mark Noel: Yeah. I think the biggest thing there is, and we've started doing this over the last year or so, is working with the self-insured employers to actually do just a, what we call a retrospective review.
So they go to their TPA and say, I want to give, first of all, I want my data, it's mine. There are issues that come with that as well that that have been opened up over the last couple of years, which is helpful. There are still some issues there, but so what we do is we typically work with that self-insured employer to get their data and do a retrospective review for them to show them where they are still overpaying.
It's less of a pay and chase model. It's more of just an overview on here's how you've paid your claims the last couple of years. And there are cases where there are some pretty obvious overpayments. And we actually will go and try to recover those for them. We do that separately.
But the, the biggest thing is just putting in front of them, here's what you've done. Here's where you're overpaying, and you can use this data either to negotiate a new contract or to kind of open up some, some windows for getting your data. But you also need to be pushing your administrator to make sure they're doing this on a prepaid basis because you're missing out on these dollars.
You're just way overspending. That's been our key.
[00:24:13] Stacey Richter: Yeah. So I can understand why you would do that retrospective. I mean, knowledge is power. Right? And that would also help you figure out what edits and policies you wanna turn on and which ones you're not concerned about. Because like, you might notice that there's just hundreds or thousands of double pays or whatever. So you're like, okay.
When you said negotiate your contract, do you mean with the TPA at that juncture or like with hospital systems or something?
[00:24:37] Mark Noel: Yeah, with the TPA or the network, if you will, right, to say, number one, you must be doing prepay editing, and it must include all of these areas. If not, I want to use ClaimInsight or I want to use another company like ClaimInsight to do it. So go make that happen.
And so they can force their TPA if they're large enough from what I've seen. Typically it takes some volume there, but they can force them to work with us and say, you know, I appreciate what you're doing, but I need, I need more.
And I know this company can help me. I wanna work with them.
[00:25:04] Stacey Richter: Well, it also could be a reason for kind of a decision making factor for a self-insured employer or other plan sponsor to pick a TPA, you know, to ask what their selection of prepay integrity vendors include.
[00:25:18] Mark Noel: That's exactly right.
[00:25:19] Stacey Richter: Because if they say we have one and we own them, then I...
[00:25:23] Mark Noel: Bingo. Yeah, that's exactly right. Yeah. Which is what typically happens with the larger ones, right? They already have that in-house, but it kind of goes back to the point I was making earlier of even though they have it in-house, they're likely still not editing to the same level that they are with their fully insured group. And that's just a fact that we've seen.
[00:25:40] Stacey Richter: And these same points did come up and there was a show with Dawn Cornelis, there was a show with Kimberly Carleson on the postpayment side of the equation.
[00:25:48] Mark Noel: That's right. And you know, there are certain things I think that you're always gonna find on the postpay side that you may not find on the prepay side.
I think there's always going to be that, but the majority can and should be caught in a prepay basis.
[00:26:01] Stacey Richter: Especially for these little things.
If we're talking about the data and now you said if you're gonna do the retrospective as you hook up your filter to the data feed that has to happen on the TPA side. Do you wanna talk a little bit the, the whole cannot get data thing has come up, long-time listeners are just like, yeah, probably 90 times in the last 90 shows.
[00:26:22] Mark Noel: Exactly. Right, right, right.
[00:26:23] Stacey Richter: So how does this work? Is this tough?
[00:26:27] Mark Noel: It's not, no. It’s not tough on the prepay side. Once you have the agreement to do it and the willingness to do it the integration is rather simple. It's not technically hard.
[00:26:37] Stacey Richter: I wanna think about this in the larger context and the larger ecosystem because you've got RCM vendors, revenue cycle management vendors on the provider side.
Dawn Cornelis brought up watch whether the payment integrity vendor is owned by the same entity that owns the revenue cycle management vendor because that's frequent. If when you start thinking about it, you're like, that's nuts.
But you know, most provider organizations these days have revenue cycle management. How do you interact with them and the more sophisticated the revenue cycle management gets, does that almost require prepayment integrity to become equally sophisticated?
Like I could see that this is a bit of a tug of war here.
[00:27:25] Mark Noel: Yes, absolutely. Yeah, it is. It's a tug of war, and honestly, it's a zero sum game, right? Because you have the folks on the front trying to maximize revenue, and you have the folks on the back backend using payment integrity vendors to ensure they're paying essentially the least amount that they have to.
It's imperative that the payment integrity vendor you're working with, whether they're using AI or manual resources or whatever. It’s imperative that they're keeping their policies up to date as to the minute, because these things change all the time. And revenue cycle management side is gonna be up to date. We need to make sure payment integrity is up to date.
So whether that's finding and building new policies or keeping the other ones that you already have up to date, it's really, really important. There are annual updates coming up here as of January 1st. It's imperative that your payment integrity vendor has all of their edits and rules up to date as of January 1st with those updates. It's things like that.
[00:28:19] Stacey Richter: Yeah, it definitely feels like an arms race there.
[00:28:21] Mark Noel: It's an arms race.
[00:28:22] Stacey Richter: Basically what we're talking about is what is the efficiency of transactions the less automated, this whole back and forth, the more that friction is going to accrue to patients and plan sponsors.
You do have the clearinghouses in the middle there and the efficiency of those clearinghouses to just even enable a prepayment integrity vendor just see what those claims are.
And we just had a whole conversation last week about clearinghouses and how sometimes claims are batched and it can be days in between the receipt of a claim and the submission of a claim. How does that affect what you're doing?
[00:29:05] Mark Noel: Yeah, because that could also impact the sequence to which we receive those claims, which goes back to my prior point of when these things are received outta sequence, there are some payment integrity vendors that can't catch that and can't figure that out. Right? And because it was sent outta sequence, it's like, oh, well they're gonna have to just be paid.
Whereas you should ensure your payment integrity vendor is actually able to piece that visit or that day back together for that patient. Call it, you know, sequence of events or whatever it's called, and they have to put it back together to say, “Oh no, since you bill these three things out of order, you actually shouldn't have paid for this one or this one, and only this one.”
So yes, it's imperative, and having those things automated, it has to happen. Again, there are some manual reviews and audits of larger claims typically, and that'll continue to happen. But, again, going back to the 80% of things being small dollar, it has to be automated.
[00:29:56] Stacey Richter: What I'm piecing together right now, just putting together the show from the episode from last week with Zack Kanter about clearinghouses with this one this week about payment integrity.
In an ideal world, all of this would be programmatic. If a claim could get shut out instantly it hits prepayment integrity, it comes back, this is a double bill, or we're not paying for this. Then you've got a provider organization who's making choices and who understands what the deal is now, not retrospectively, 4 months later.
[00:30:28] Mark Noel: Yeah, and we continue to have discussions even upstream from the TPA. We have discussions with clearinghouses. We have discussions with the networks that simply do the pricing of those claims to see where's the best place to add payment integrity. And really it's everywhere.
You know, if a clearinghouse can determine something was a duplicate, why wouldn't you deny it there?
Why does it need to keep going down the process? Right? And so those are some of the discussions we have as well, because that's important.
[00:30:52] Stacey Richter: What is your advice for plan sponsors? So we've just touched on a lot of different areas where, you know, again, transactions can break down, things can get through the barrier.
You've got people with financial incentives to kinda let 'em go through because they're getting paid on the back end. You know, a percentage of the “savings”.
What should somebody do as a self-insured employer right now, or a plan sponsor?
[00:31:18] Mark Noel: Step 1: you go and get a retrospective review of your claims from your processor that shows how were my claims paid last year, what type of reviews were done on them, what type of payment integrity was done on that, and what were those results? That's really important.
And then what I would do is take those results and talk to people, talk to your broker about those results. Talk to somebody that you trust as a payment integrity, subject matter expert. May or may not be your broker, may or may not be a vendor that you've worked with. We do this all day long. Take it to those folks and just get, get in a room and kind of get the results out on the table.
The TPAs, in many cases, they are doing something. They may just not be doing it to the level that you, as the plan sponsor believe you need to be. Then ask questions. Every dollar that's overspent is a dollar that should have been back in your pockets.
[00:32:03] Stacey Richter: You said ask questions. What are the questions?
[00:32:05] Mark Noel: What is happening today with for payment integrity on my claims? What is the process? Is it happening prepayment? Is it happening post-payment? How am I paying for that? What are the fees? Who's doing it?
Show me the results of the most recent analysis that's been done that shows, you know, a hundred thousand dollars was gonna be paid and we only paid up 90,000 because we found 10,000 savings.
Getting that data in your hands so you can feel good about it because again, these are, these plan sponsors are the fiduciary of that money. And they don't want to end up in a lawsuit like, like we've seen. And so getting involved in staying involved is really important.
[00:32:38] Stacey Richter: Yeah, it definitely sounds like just given the level of perverse incentives that are afoot here.
And we all know we've got incentives to let claims go through. We've got revenue cycle management and payment integrity being owned by the same company.
We also, of course, have instances where brokers are being compensated by TPAs for things, right? So like there's a lot that's going on here and knowledge is power. And what I'm hearing you say, go get that retrospective so you've got something to eyeball and something to look at, and then ask hard questions.
If we've got millions of dollars that's leaking out the edges on duplicate claims or whatever, like this is not spend that is accruing to better patient care. This is a hundred percent waste. And even if it's not done on purpose and not done because of the perverse incentives, it's just happening, it's still a lot of money.
You know, these are the inches that are all around us.
[00:33:37] Mark Noel: That's exactly right. And I think that's the biggest point. There are dollars that should be back in your coffers to be placed on patient care.
[00:33:44] Stacey Richter: Mark Noel, if someone is interested in learning more about prepayment integrity or ClaimInsight, where would you direct them?
[00:33:51] Mark Noel: Yeah. Thanks for that. I love to talk about this stuff. I talk about it all day. Very passionate about it. I've been talking about it for 25 years. Honestly, call me. Love to talk about it. Love to take a look at your claims with you and and go through what you're seeing and give you my opinion, my take on it.
Happy to do that.
[00:34:06] Stacey Richter: Mark Noel, thank you so much for being on Relentless Health Value today.
[00:34:09] Mark Noel: Thank you very much. Really appreciate it. This was a blast.