From Outsource to Insource: Your Roadmap to Seamlessly Bring Payment Integrity Back Home

Health plans are increasingly finding themselves caught in a costly cycle, investing significant resources in multiple external payment integrity (PI) vendors only to find the same overpayments being flagged time and time again and an increase in provider abrasion issues. This not only consumes precious financial resources but also dilutes operational efficiency. Fortunately, there is a more streamlined and cost-effective solution—your in-house team. Far from being merely a recovery center, your internal team can be transformed into an intelligence powerhouse that gets payment accuracy right from the start.

Here’s how to leverage the power of your team and a trusted PI consulting partner to streamline your PI processes.

1. Assess the current state

To determine future state, it is important to evaluate current state. This assessment will help identify the areas where insourcing is most beneficial. Insourcing requires careful planning and execution and includes an in-depth review of organizational resources, including staff, existing vendors, processes and procedures, technology, the claims editing scenarios, and data analytics.

2. Develop standardized processes, workflows, and training through expert guidance

The cornerstone of a successful in-house PI operation is your team. The first step in this transformative journey is to harness the power of your existing resources and equip them with the right processes, technologies, tools, and training. An effective PI partner can provide an in-depth review of existing processes and workflows, develop the necessary training, establish effective workflows, and hone your team’s ability to spot and fix systemic errors. This upskilling strategy can notably enhance your operation’s efficiency and financial performance.

3. Build a best-in-class team with partner support

Creating an outstanding in-house PI program necessitates assembling the right team. Look for a partner who can help you craft precise job descriptions, shortlist potential candidates, and even assist with the hiring process. An established PI partner knows exactly which roles to create and the key qualities to look for when it comes to bringing in top talent, enabling you to cultivate a top-tier in-house PI division that drives success.

4. Leverage technology and train your people to master it

An exceptional PI partner is one who truly invests in your success. Their role extends beyond providing services—they are there to empower your in-house PI team with innovative technology and comprehensive training to wield it proficiently. Your team, armed with the right tools and knowledge, will become masters at identifying and resolving payment discrepancies, constructing effective audit scenarios, and tracing the root-cause of overpayments. The transformation of your team into a powerhouse of efficiency and accuracy is a testament to the positive impact of making this strategic shift. With such a robust system in place, you’ll find yourself reflecting on why you hadn’t transitioned sooner.

Bringing payment integrity in-house offers health plans unparalleled control over their auditing processes. Traditional contingency outsourcing risks encountering vendors who are unwilling to provide the root-causes of overpayments, resulting in repeated errors, added expense, and provider abrasion. Transitioning to an in-house payment integrity process, especially with the support of a trusted partner, empowers health plans to oversee their entire review procedures. It’s a move towards operational efficiency, flexibility, and cost-effectiveness.

Editor’s Note:
Penstock is an exemplary payment integrity partner that can help you navigate the transformation. With an in-depth understanding of the intricacies of payment integrity, coupled with top-notch technological solutions, Penstock is equipped to empower your team and drive your transition towards a robust, in-house PI operation. Their commitment to fostering excellence makes them the perfect ally in your quest for control, transparency, and accuracy from the start—when it matters most.

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