How payers can manage ‘unwinding’ challenges in Medicaid and CHIP

These six data-driven anti-fraud member engagement practices can help organizations connect with members after the public health emergency.

Systems and operational issues are at least partially to blame for the recent chaos in Medicaid and Children’s Health Insurance Program (CHIP) disenrollments, which have left millions without healthcare coverage.

The challenges began this past spring, when rules that kept Medicaid and CHIP beneficiaries automatically enrolled throughout the COVID-19 public health emergency came to end, launching the “unwinding” period for states to resume eligibility reviews. In late August, inappropriate disenrollments prompted the federal government to step in and temporarily halt the process in most states.

While health plans have yet to realize the full impact of disenrollments, there is another post-pandemic threat that puts their businesses and members at risk – new fraud, waste and abuse schemes. The surge in telehealth and behavioral health, coupled with relaxed regulations during the pandemic, helped foment new types of waste and abuse that persist today.

But it’s not all bad news. Forward-thinking health plans are using their knowledge of these new payment schemes as power and doubling down on their payment integrity efforts to safeguard finances amid the uncertainty. At the same time, payers are optimizing their re-enrollment processes to help families get the coverage and care they need while building robust member profiles to drive their population health efforts.

Here are six strategies for plans to stay ahead of these payment and engagement challenges now and through 2024.

Focus efforts on behavioral health and telehealth. Our analysis of data from several health plans shows the volume of behavioral health procedure codes in telehealth rose from less than 1 percent in 2019 to nearly 40 percent in 2022. Creative billing practices have also increased alongside that rise in volume, with no signs of easing post-pandemic, as many telehealth flexibilities remain in place following expiration of the public health emergency.

In addition to knowing which areas are prone to fraud and abuse, it’s also important for plans to stay aware of the potential warning signs of inappropriate behavior. For example, investigators should be wary of behavioral health providers using the same anxiety disorder codes for patients across all services, as well as those delivering most services via telehealth who have also expanded their geographic reach.

Significant spikes in payment integrity automated edits could indicate potential fraud, such as a provider increasing claims volumes to offset revenue loss. Similarly, a decrease could indicate that the provider identified a new billing pattern to evade detection of automated edits.

Give payment integrity teams the right tools. Many plans continue to struggle to recruit and retain investigators in this competitive market. However, equipping teams with AI and machine learning capabilities can make overwhelmed investigators more effective at identifying new patterns of suspicious behavior.

Analytics can also help identify questionable spend areas by service and procedure code, as one example. With such tools, teams can also quickly identify and adapt to new and emerging trends and schemes, such as those that arose during the public health emergency.

Don’t let competition get in the way of collaboration to thwart bad actors. Even though payers thrive on healthy competition with one another, fraud, waste and abuse detection efforts can benefit from partnership.

Sharing insights on suspicious claims in different geographic areas can help plans focus resources on potential hot spots. This payer-payer collaboration to uncover fraud, waste and abuse trends can be especially useful for small- and medium-sized plans that have a regional focus.

During redetermination, use several methods to reach members. Ensuring your plan has a single source of truth for member profiles should be a top priority within redetermination campaigns in this unwinding period. But motivating members to provide this information remains a challenge.

Some plans are using multipronged member engagement tactics based on behavioral science to inform members about potential coverage loss and encourage them to act. Over the course of nine months, these plans reached about 4.5 million members in half the time as traditional campaigns and saw more than 70 percent of texts delivered, 35 percent of emails opened and 85 percent of live agent calls connected. On average, four out of five members confirmed their addresses, avoiding disenrollment because of procedural issues. About 98 percent of transfers back to the plans were successful, providing members with more opportunities to complete renewal paperwork and obtain information needed to confirm their eligibility.

Prioritize members’ social needs after the pandemic. Besides educating members about their benefits, some plans have used the redetermination process to gather social determinants of health data. This is critical for plans to address health inequities that may have worsened for people of color and other underserved populations during the pandemic.

Asking questions related to barriers, such as lack of transportation to medical visits, can help payers better understand the needs of their members and connect them to appropriate community-based services.

One regional managed Medicaid plan leveraged its redetermination process to gain insights on members’ needs. After Medicaid beneficiaries were transferred to the health plan after a redetermination call, health navigators captured members’ contact information, assessed their social needs and stayed on the call while they connected members to appropriate community-based resources.

Ensure year-round outreach offers benefits to members. Staying connected to members throughout the calendar year can help build a connection and increase the success of outreach programs. Calls, texts or emails that link members to educational videos, health navigators or other types of support offer real value and can keep the communication lines open.

Looking ahead to 2024

Although the pandemic is behind us, payers are still dealing with its aftermath, which includes lingering and newly emerging challenges related to payment integrity and member engagement.

As plans look ahead to 2024, health plans must reflect on the lessons learned from the public health emergency — like how quickly the payment landscape can change without warning —so they can remain vigilant about potential new schemes emerging from future catastrophic events and regulatory flexibilities.

It’s also an ideal time to review which member engagement strategies have been most effective with at-risk populations, particularly as plans aim to improve clinical outcomes and health equity metrics in the coming year. Combined with the strategies discussed in this article, this self-reflection can help plans prepare for future seismic shifts in the industry.

Erin Rutzler is vice president of fraud, waste and abuse and Leah Dewey is vice president of clinical and consumer engagement operations for Cotiviti.

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