Part I: Establishing PI benchmarks is highly complex
For several years, industry benchmarking for payment integrity has been discussed - and several stakeholders have attempted to solve the problem. At Kisaco Research’s 2024 HPRI conference in Miami, payment integrity thought leaders convened to discuss industry challenges and opportunities, and a clear theme emerged: the urgent need for standardization and industry benchmarking to better understand performance.
The Challenge
Benchmarks have been tried before: Some of the largest health plans and vendors have attempted to develop financial benchmarks for PI. Efforts stalled or are not comprehensive or translatable.
If you’ve seen one health plan’s metrics - you’ve seen one health plan’s metrics: 5-7% savings as a percentage of medical spend or broad ranges of savings PMPY are ineffective without a standard approach to defining, calculating, and segmenting the metrics.
It's not easy: Standardization is very difficult. Payment integrity programs vary in structure, maturity, and methodologies. In addition, plans and vendor partners are rightfully hesitant to share performance metrics with each other.
The Solution: Industry Collaboration Supported by Independent Research Company
Through discussions with payment integrity leaders, Kisaco Research determined the best approach was to develop a collaborative working group of industry experts with a passion for metrics. The group now includes ~15 participants who volunteer their time to develop guidance on key standards and metrics. Kisaco Research is acting as an independent coordinator and facilitator to guide the process and ensure confidentiality.
The Working Group determined that that the above challenges underscore the need for a highly disciplined, collaborative approach focused on the following core values:
Start with the fundamentals. An essential first step is to develop standard definitions and calculations for PI programs and metrics, and to define levels of segmentation that support alignment between plans. These norms will then be applied to enable comparable metrics.
Collaboration is critical. The Working Group will share proposed guidance, gather industry-wide feedback from all types of plans and vendor partners, and publish recommendations.
Progress over perfection. Every PI program is structured differently. While guidance may not fully align with a plan’s existing data systems or reporting, we will provide a flexible framework and support to drive progress.
Progress
Guided by these core values, the Working Group is focused on proposing standard definitions and calculations for Savings PMPM. Read more about our proposed guidance in Part II of this series.