Transforming Payment Integrity Value: The CoverSelf Revolution

Jul 2, 2024
5 min read
Sukhwinder Lamba
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Coverself | How Do You Look for Symptoms of Issues in Your Health Plan?

In earlier months, we started a series of three articles. In the first article earlier this year (, we began a crucial discussion on the symptoms of issues in health plans. Continuing this series, in the second article, we delved into the problems or causes that hinder health plans from effectively addressing those symptoms ( In this series' third and last article, we describe the values that CoverSelf, an effective payment integrity solution, delivers to tackle the above causes. Each of the causes or problems in healthcare payment integrity we described earlier needs a practical solution supported by proper technologies and business models. Let's examine each of these value points below.

Transparency: Coverself is designed to bring transparency to the payment integrity process. It enables payers and providers to identify inaccuracies in health claims and understand the root causes, facilitating more efficient resolution. Traditional payment integrity vendors provide black-box solutions that make it difficult to understand the issues causing medical claim inaccuracies. Transparency brings a fresh approach to solving back-and-forth issues on medical claims, which saves time & resources for both payers and providers. With transparency, payers and providers can focus on solving problems in medical claims rather than conflicting with each other.

CoverSelf fosters a collaborative environment, enhancing transparency for payers through modern UX/UI, a cloud-native platform, and robust business intelligence capabilities. Central to this is CREOL, a patent-pending, intuitive configuration language that simplifies the setup and management of payment integrity processes. The user-friendly interface ensures ease of use, fostering a transparent and collaborative environment for swiftly identifying and addressing claim inaccuracies. CoverSelf's cloud-native platform provides real-time data access and seamless system integration, enhancing visibility across the payment integrity process. Furthermore, CoverSelf's business intelligence tools offer real-time claims monitoring and reporting, supporting quick decision-making and prioritization. Key features include comparison metrics to measure performance over time, an ideation pipeline to highlight areas of opportunity, interactive dashboards with drill-down capabilities for in-depth data exploration, and payment intelligence for timely, effective decision-making based on current trends and anomalies. Together, the above technologies ensure openness, efficiency, and continuous improvement in claims management, enabling payers to resolve issues collaboratively with providers.

Alignment of Interests: Traditional payment integrity vendors often benefit from payment inaccuracies because they earn more as inaccuracies persist. Their black box approach enhances this misalignment of interest. In contrast, CoverSelf encourages the reduction of inaccuracies, aligning with Payers' interests.

CoverSelf's core business model offers a platform approach that is not directly tied to the medical claims’ inaccuracies. Key technologies integrated into the CoverSelf platform further support the alignment. For example, CoverSelf offers built-in industry code sets and continuously auto-updated policies, ensuring accuracy and compliance. The platform's "DIY( Do-It-Yourself) or Delegate" feature allows payers to configure policies, write proprietary business rules effortlessly, or delegate these tasks to CoverSelf, maintaining flexibility and control. The policy management system enables users to ideate, create, customize, manage, test, and publish policies and scenarios quickly without losing intellectual property.

CoverSelf's platform is extendable to all healthcare lines of business (LOBs), providing pre- and post-pay capabilities. Its rapid release capabilities ensure that updates and new features are deployed within hours, supported by an enforced workflow that maintains consistency and reliability. Continuous testing, designed with a quality-first approach, ensures the platform remains robust and accurate. These technologies collectively promote an efficient system that aligns with payers' interests, reducing inaccuracies and fostering a collaborative approach to payment integrity between providers and payers.

Empowering Payment Integrity Teams: CoverSelf empowers the payers' payment integrity team by providing them with tools and insights to participate actively in the resolution process. Traditional payment integrity vendors follow a black-box approach that makes payers lose control of the medical claims process.

CoverSelf's hyper-customization and versioning allow for tailored solutions at the LOB and plan levels, ensuring that the platform meets specific needs. Payers can also maintain a private rules repository, protecting their proprietary rules and intellectual property without sharing them, even with CoverSelf. Thus, CoverSelf offers complete control for payers' internal payment integrity teams.

The Payer-specific claims auto-correction feature automatically corrects and processes claims, reducing the workload for the in-house team and ensuring accuracy. Additionally, the platform is extendable to pre-pay and post-pay capabilities, further enhancing flexibility and control. These CoverSelf technologies collectively enable payers' payment integrity teams to manage and resolve claims actively, ensuring they have the necessary tools to protect their interests and keep oversight of the entire process. This empowerment leads to more efficient and accurate claims processing.

In-House Payment Integrity: CoverSelf allows Payers to bring the payment integrity solution in-house, reducing reliance on external vendors. This shift in control helps Payers to have a more direct and efficient approach to resolving inaccuracies.

CoverSelf technologies that make it easy to self-manage ensure that payers can move payment integrity in-house. Various levels of automation and the solution's simple, intuitive nature cut the in-house team's learning curve. The technologies discussed above in the Transparency, Alignment of Interest, and Empowerment of Internal Payment Integrity teams' sections are all relevant for bringing the Payment Integrity function in-house.

Cost Reduction: The increasing cost of traditional payment integrity vendors has become unsustainable for payers.  CoverSelf aims to reduce the number of payment integrity vendors and offers a much more affordable solution.

CoverSelf's key technologies reduce payers' costs by enabling self-management, automation, and a choice of pre-configured industry code sets. In addition, offering pre-pay and post-pay options helps tackle claims' inaccuracies at the proper stage to reduce costs as soon as possible.

Moreover, CoverSelf's ideation platform helps identify new savings opportunities. It empowers domain experts to ideate, create, validate, test, and implement rules and new concepts on the fly without high technical dependency, enhancing innovation while controlling costs. The "What-if" scenarios, "Impact Analysis," and "Speed to Release" technologies enable a high return on investment (ROI).  

Comprehensive Solution:  As described in the previous article in this series, payer companies yearn for comprehensive solutions that consolidate disparate functions into a unified platform and offer seamless integration. CoverSelf solution has a unique approach that could help payers realize that vision. With a Self-Directed Domain-Specific Platform for Claim editing, an Ideation platform to quickly identify new savings, payment intelligence functions for real-time insights, and a state-of-the-art cloud-based approach, CoverSelf’s value spans various facets of the payment integrity domain.

Additionally, Coverself is an open platform that could quickly integrate and digest any additional specific function that payers need to provide extended value in the payment integrity domain.

In conclusion, the CoverSelf platform is a game-changer in the payment integrity landscape. By providing a self-managed, transparent, and automated solution, CoverSelf brings control back to the payers. CoverSelf addresses current challenges in healthcare payment integrity and paves the way for a more efficient, transparent, and cost-effective future.