Amy Johnson is a senior customer success manager for Shift clients in the healthcare space.
In this installment of the “Four Questions With” series we talk with Amy about her career in the healthcare space and how she transferred that experience into her current role at Shift. We also tackle the intersection between payment integrity and operations, how payers can think differently about payment integrity, and naturally, where does AI fit into the equation.
How did your career trajectory lead you to Shift?
I started my career in healthcare as a medical receptionist—and soon after promoted to manager—in a mental health and substance abuse clinic. I had my first experiences there participating in both sides of the health payer equation through direct contact from a customer service standpoint but also working with providers and clinicians and submitting claims.
From there I joined a health plan on the mental health side of the house where I started out managing authorizations. I ended up spending nearly 25 years at the company with responsibility for several operations roles including client relations and financial management. I also dealt with Commercial, Medicare, and Medicaid and received a good education in state government through my state clients.
From working with health plans I took that expertise into the world of SaaS solutions for the health payer industry. The company I was with focused primarily on solutions covering operational areas such as appeals and grievances, enrollment and also compliance. And that leap into healthcare SaaS brought me to Shift. I wanted to take what I’d learned about health plan operations and help make the connection to payment integrity, because the two areas really are closely intertwined, or should be.
Where is that intersection between payment integrity and operations and what is the impact?
What’s interesting to me is that when you take a step back to look at the big picture there really isn’t one, single, intersecting point. There’s no one place where you can say, “oh, so this is where payment integrity and operations meet.” Fundamentally, a plan’s payment integrity strategy can either positively or negatively impact operations throughout the process.
Think about what happens when you put a provider on review, for whatever reason. The time required to do medical record review, on every claim, is incredible. And while the rationale may seem sound—you want to catch any issues before payment is made—you’re impacting the finance department who wants to get providers paid, you’re impacting provider relations, you may be impacting compliance. The list goes on and on.
But, if you begin thinking about payment integrity differently, you can positively influence operations across the organization. Simply put, greater efficiency in payment integrity equals greater efficiency throughout the organization. Imagine needing to perform a records review only on claims that exhibit aberrations and not every single claim coming from a provider or provider organization. The time savings alone are immense. But what you’ve also done is freed employees to focus on more impactful activities that will reap long-term benefits.
What exactly do you mean by “thinking differently” about payment integrity?
Legacy approaches to payment integrity are typically focused on confirming three things; is the patient covered by the plan, does the plan cover the treatment, and is the payment being claimed within the strictures set by the plan. It’s a great start, but it also leaves payer organizations exposed to a lot of risk. So when I talk about thinking differently about payment integrity it’s all about reducing that exposure and mitigating risk. It’s all about getting away from thinking about fraud, waste, and abuse after the fact and then needing to resort to “pay and chase” after an illegitimate claim, or claims, have been paid. It’s about knowing not only who your providers are, but also who they’re connected with. And whether or not those relationships expose the plan to further risk.
Thinking differently about payment integrity is also about being open to more automation. But that doesn’t mean automate everything. Plans need to be strategic about what can, and perhaps more importantly should, be automated. Or even can sub-tasks within the process be automated. The more plans move away from time-consuming manual processes and procedures the more they can focus on member outcomes.
What role do you see artificial intelligence playing in how plans rethink payment integrity?
AI is an amazing efficiency engine. It’s what allows us to analyze individual claims before payment and flag any inconsistencies, signs of FWA, or other anomalies for further review and investigation. AI, and in this case more specifically generative AI, can read and summarize medical records making relevant content available to reviewers for their professional assessment. AI can help plans better understand the activities of their providers, not only through analysis of claims they’ve filed but also by bringing in third-party and outside data that may indicate patterns of behavior. Trying to do all of these things manually is simply untenable.
AI allows plans to understand what is happening with individual claims before payment, giving them an opportunity to pinpoint billing errors or investigate suspicious activity while at the same time streamlining payment for legitimate claims. And should a claim slip through, post-pay analysis gives you the opportunity to seek reimbursement while at the same time providing feedback that can strengthen your pre-pay models.
Fundamentally, plans strive to do what’s best for their provider network, for their members, and the business. AI is a powerful tool that can help them achieve their goals and elevate their payment integrity initiatives.