Lisa Hornick BA, CPC, CPMA, CEDC, CPhT, AAPC Approved Instructor is a senior customer success manager for Shift clients in the healthcare space.
In this installment of the “4 Questions with” series we talk with Lisa about the career path that brought her to Shift, her thoughts on payment integrity’s evolution throughout the years, the role artificial intelligence (AI) has played, and will continue to play, in changing how the industry thinks about payment integrity, and why we need to broaden our thinking about payment integrity.
A quick glance at your LinkedIn profile shows a truly interesting career from pharmacy technician to being part of the customer success team for Shift. Can you tell us a little more about your journey?
When I take a step back and look at my career, how I got here from there makes a lot of sense to me. My time as a certified pharmacy technician and allied health instructor exposed me to not only the clinical side of medicine but also the business side—particularly health insurance management. From there, it felt like a natural progression to apply my experience to high-cost drug auditing. I was responsible for reviewing medical drug claims, across multiple accounts, to identify instances of overpayments. And from auditing I moved into medical coding and began working in the payer space. I handled appeals, medical records review, and worked with providers to resolve any issues to ensure they had a good experience working with our organization. From coding, I moved into ideation where I initiated cost savings initiatives and ensured compliance—all with the goal of saving money for the company and reducing premiums.
Ultimately, I was promoted to coding manager with oversight of coding appeals, the SIU, payment integrity, and ideation. It was there that I began to really understand the impact technology could have on the payment integrity process and I wanted to be a part of that. So, naturally I came to Shift.
How have you seen payment integrity evolve over the course of your career?
I’ve worked in payment integrity for more than a decade now and have witnessed a ton of changes. When the term “payment integrity” was first introduced it was really kind of a buzzword. Payers would say they had a payment integrity division, but the impact was negligible. From there, the industry moved into what many still think of as payment integrity, a basic check of coverage and services provided. Essentially, payment integrity was all about determining if the patient is a plan member, is the service being billed is covered by the plan and is the rate within contracted guidelines. And don’t get me wrong, it’s a good start. But as we’ve seen over the years, it’s a system that can be easily manipulated. Claims that look legitimate on the surface can be hiding any number of inaccuracies, misrepresentations, or other aberrations. If they’re not found before the claim gets paid, now you need to try and get it back.
What we’re beginning to see emerge is a new way of thinking about payment integrity that goes beyond the basics. Aided by technologies such as artificial intelligence, payers are thinking about payment integrity much more holistically by incorporating elements of entity resolution, and fraud, waste, and abuse detection. They’re looking for what may be honest mistakes, but still have the potential to significantly impact the business. It’s truly an exciting time to be in the payment integrity space. I can’t wait to see what’s next!
You mentioned artificial intelligence. In your opinion, how is AI reshaping what’s possible in the payment integrity space?
AI is really all about bringing greater efficiency, accuracy, and transparency to payment integrity. It gives payers the power to look deeper at individual claims—before they’re paid—to ensure everything’s in order. It can help spot claims anomalies that may go unnoticed, especially when that behavior is associated with networks or providers acting in concert. And because AI can analyze individual claims with incredible speed and reliability, payers can avoid actions such as putting an entire medical practice’s claims under medical records review. This removes friction from the system, ensures legitimate claims are paid promptly and fairly, and helps manage premiums. AI-powered payment integrity is a benefit for everyone involved in the health payer ecosystem, unless you’re trying to take advantage of it of course.
What do you think is next for payment integrity?
I think we’re going to see plans and payer organizations thinking differently about payment integrity. And I see that happening in a couple of ways. We’re going to see payment integrity looking a lot more like a closed loop system where pre-pay and post-pay analysis inform each other to drive incredible visibility into what’s happening with individual claims, providers, and networks. It’s a really powerful proposition.
I also think we’re going to begin seeing how AI can help break down the silos that may be limiting the effectiveness of current payment integrity strategies. Take dental benefits for example. We often see dental benefits submitted and paid on a medical plan because the provider is both an oral maxillofacial surgeon and a dentist. They can bill for all their cleanings and then they can do a little surgery here or there, or Botox for TMJ. There are so many different scenarios where a dentist could bill against medical benefits as opposed to dental. There are just a ton of opportunities where you see crossover of specialty benefits into medical benefits, and being able to clearly see the big picture—which AI offers—can really drive good decisions.