RamaOnHealthcare June 13, 2022

Today, RamaOnHealthcare talks with Ryan Mooney, who leads the mission to reform payment integrity for health plans as part of HealthEdge’s digital transformation of healthcare. He is passionate about driving transparency into the industry’s payment integrity practices to improve relationships between providers and payers, and to cut waste from the system.

Ryan Mooney, General Manager, Source Division, HealthEdge

Ryan Mooney, General Manager, Source Division, HealthEdge

RamaOnHealthcare (ROH): You and your business serve a wide range of payer organizations and see all the pitfalls in current payment integrity operations. Can you give us an overview of the current state of things?

Ryan Mooney (RM): Absolutely. I’ve been working in payment integrity for over 24 years, and throughout this experience I’ve found it nearly impossible not to run into issues within the system. Payment integrity is about the proper management of payments – accuracy and timeliness – and any payer client will tell you they believe they are efficient and you won’t find problems. But as a team that’s solely devoted to payment integrity, you always do. Payment integrity unearths all the places that are broken and tries to set them right. This is a noble cause. Unfortunately, there are structural problems because if you depend on the contingency model – the vendor gets paid according to the quantity of errors they find – the core problem will continue. This is one of the many perverse incentives of healthcare – vendors who find things that are incorrect make more money. The more errors, the more financial reward. Segments of the payment integrity industry like it this way, but we don’t. We want to root out the problems that are dormant as the root cause of a dysfunctional practice and hurt the long-term integrity of the healthcare system. When a payment integrity vendor comes back quarter after quarter with the same problems, there’s a multiplier effect – they just grow over time and never “heal.” The sad part is many of these problems would be easy fixes.

Payment integrity unearths all the places that are broken and tries to set them right. This is a noble cause.

Unfortunately, many vendors in this space see this as the pathway to their organization’s growth and we also think that’s wrong. There are plenty of ways to grow your business but feeding into a bad system is not serving the greater good. So, health plans need to have transparency to understand what the patterns are – to see into the “black box” that prevents them from identifying systemic issues. Digital transformation means lifting the lid on that box and using data to solve real problems. It is a viable business model that everyone in this space – especially payers – ought to be embracing.

There are plenty of ways to grow your business but feeding into a bad system is not serving the greater good.

ROH: Thank you for the overview and for your thoughts on this, Ryan. Before diving deeper can you just give us an idea of how many payers are using this type of model?

RM: Most payers depend on the contingency model, which some in the industry also call “gain share.” So, a payer-integrity vendor might scrape $20 off every hundred dollars in errors they find. At first it seems like a low-risk model, but over time it becomes less beneficial to payers, especially if a steady stream of recurring issues crops up. Payers can do themselves a favor by seeing into the black box.

ROH: If this is the model that most payers operate under, how can they start doing things differently? Does it all come down to a digital approach? How can payers break this cycle?

RM: I think we’re evolving and moving in the right direction. People want to find ways to improve their current processes without sacrificing growth. The key is going to be a major focus on data and analytics. A streamlined platform is critical to liberate us from manual processes and to free up people to act on problems on their own. It’s a big task to sort through data, but it can be made much easier. The fundamentals must be right before you address the more complex issues. In a complex payer environment, a single platform with all the right tools tied into analytics is really the answer. Then that payer can look at the outliers that are causing repeated problems themselves, instead of depending on a vendor to bring them to light.

People want to find ways to improve their current processes without sacrificing growth. The key is going to be a major focus on data and analytics. A streamlined platform is critical to liberate us from manual processes and to free up people to act on problems on their own.

ROH: That all makes sense – so if there’s technology to solve for this, why aren’t payers investing in this?

RM: Oh, but they are starting to. They are investing more than ever before in payment integrity. They are frustrated and catching onto the fact that they constantly have the same issues and those issues cost them money. Payers are starting to invest more in their own teams and bringing more capabilities into their own wheelhouse, so they have greater control. Any vendor doing it differently is costing that payer more. Payers are seeing this. Transparency and a degree of trust must be there for vendors to open up that black box.

Payers are starting to invest more in their own teams and bringing more capabilities into their own wheelhouse, so they have greater control. Any vendor doing it differently is costing that payer more. Payers are seeing this.

ROH: It’s been reported that an estimated $760 billion to $935 billion is wasted in healthcare spending annually. Presumably, everyone wants to solve that. What can providers do to help in this segment of the system?

RM: Recognize that we are all in this together and waste hurts everyone. I always tell people that if there is an opportunity to improve and we don’t do it, well, that’s just wrong. Everyone’s a patient or knows a patient or will become a patient. We need to demand that things are done the right way, all of us. You’ll always have a few bad actors among providers who will bill incorrectly and don’t want to change their behavior. But I believe most errors are just that – errors. Let’s assume that intentions are good and just work toward greater transparency and accuracy with data management, smart communication, and reimbursement structures. We need to reduce provider-payer abrasion. Getting good at analytics to identify issues, correct them, and then reconfigure whatever that root cause was is important to improving the problem. There’s always going to be change and there are always going to be new problems, so an ongoing investment needs to be made.

I always tell people that if there is an opportunity to improve and we don’t do it, well, that’s just wrong.

ROH: Thank you for sharing your thoughts on how we can improve this massive waste in annual healthcare spending. Are there any trends you’ve noticed over time that you think will continue as the payment integrity system evolves?

RM: Payers are certainly getting smarter about data management and analytics, which is a big positive. They’re starting to get the transparency they need to be able to know the context of a problem and understand how to fix it, or at least what questions to start asking. We want to see payers able to identify more and that’s probably the biggest trend I’ve seen. When you start to see the bigger picture with payment integrity vendors and see what is happening, you start to invest in a better, more sustainable way of doing things. Once you see how much money is being wasted, you invest that internally to try to remedy it. As a result, internal teams are becoming much stronger, and becoming more technically capable of managing these errors from within as opposed to outsourcing this function.

Payers are certainly getting smarter about data management and analytics…. internal teams are becoming much stronger, and becoming more technically capable of managing these errors from within as opposed to outsourcing this function.

To have happy provider networks, payers and providers need to work in unison, rather than always being at odds. A lot of payer internal teams are focusing on being communicative and transparent rather than being aggressive in making recoveries. Their role is to be the center of intelligence so that they can take on the world of payment integrity to make it better and make it right. I feel confident that if we redefined payment integrity as not recovery, but intelligence striving for accuracy, people’s thought processes would change. If people change the way they think about payment integrity, it will start to inspire people to work on improving the system in the places where it does not work so well.

…if we redefined payment integrity as not recovery, but intelligence striving for accuracy, people’s thought processes would change. If people change the way they think about payment integrity, it will start to inspire people to work on improving the system….

About Ryan Mooney

Ryan Mooney is EVP and General Manager for the Source division of HealthEdge, leading a mission to disrupt and optimize the payment integrity market by driving transparency into payment practices. His visionary, best-in-business philosophy emphasizes customer delight and genuine partnership with payers, leveraging a disciplined and innovative approach. Ryan previously served Cotiviti for 22 years and led its post-payment and digital transformation practices. Ryan attended the University of Cambridge and earned a bachelor’s degree in philosophy from the University of Washington.

 
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