Beyond the Public Health Emergency: How Health Plans Can Rise Above the Chaos

Updated on October 29, 2023

It’s been a tumultuous few months since the COVID-19 public health emergency (PHE) expired in May and unleashed new challenges for health plans, provider organizations and patients. More than 8.8 million Medicaid enrollees have been disenrolled since the unwinding of the continuous enrollment provision, which allowed individuals to keep their coverage during the pandemic.

Nearly three-fourths of disenrollments have occurred for procedural reasons, or essentially “paperwork problems.” Most states have been required to pause disenrollments over concerns that issues with auto- (or “ex parte”) renewals were disenrolling adults and children who were still eligible for Medicaid or the Children’s Health Insurance Program (CHIP). Disenrollments also prompted residents in at least one state to file a class-action lawsuit.

Amid this turmoil, the complexity of the renewal process continues to test states and managed Medicaid plans that are seeing a resurgence of enrollment churn. At the same time, health plans are still contending with billing and coding changes from the PHE, which led to new types of inappropriate payments that pose an additional business threat.

As disenrollments resume through 2024, health plans can adopt some of these approaches and best practices to engage members as part of their redetermination processes.

Don’t think it’s too late to capture member information. In the post-PHE era, leading health plans are providing Medicaid beneficiaries with information about their eligibility and alternative coverage options like marketplace plans so that members do not end up uninsured.

Ten leading plans launched redetermination campaigns, all with a focus on optimizing member engagement, well before the end of the public health emergency and prioritized their outreach according to different state timelines. From January through August 2023, these plans reached more than 4.5 million members using a multichannel approach including interactive voice response (IVR) calls, live agent calls, text messages, and emails. On average, about 83% of members confirmed their addresses, and 98% of transfers to health plans were successfully completed.

But it’s not too late for other payers who may not have been as proactive before the end of the PHE. The most effective member engagement approaches rely not only on technology, but also on behavioral science and third-party data to create customized messages that motivate members to act.

Use empathetic, culturally appropriate messaging. Redetermination can be especially challenging for people with limited English proficiency. The most effective outreach messages are culturally sensitive and delivered in each member’s preferred language. Communications developed using “transcreation” to adapt a message so that it is culturally appropriate—rather than simply translating word for word—will be most successful.

If your plan uses a partner for member outreach, choose one that has an experienced cultural communication team who can help design effective messaging based on your target population and program goals.

Embrace year-round engagement strategies. Communicating with members throughout the year—not just when trying to determine eligibility—creates rapport. Welcome calls, health risk assessments, preventive care reminders and other educational messages geared toward specific populations can help build trust.

One payer developed a highly personalized outreach campaign to connect members with health navigators, who assessed members’ social determinants of health and then directed them to community organizations for support. Another program identified new mothers with postpartum depression and helped them find the care they needed to improve clinical outcomes and boost member satisfaction.

Another challenge stemming from the pandemic is an increase in fraud, waste, and abuse (FWA). Since the pandemic began, payers have seen an uptick in upcoded services and duplicate payments due to regulatory changes that have allowed bad actors to capitalize on the shift to telehealth and the surge in demand for behavioral health services. Here are some best practices to guard against financial losses resulting from post-pandemic FWA.

Know the latest telehealth and behavioral health schemes. Upcoding evaluation and management (E&M) services, particularly for pediatric care delivered via telehealth, remains an issue post-pandemic. To offset lost reimbursement from low patient volumes during the pandemic, some bad actors may upcode 45-minute visits as 60-minute visits, just to give one example. Others may engage in questionable prescribing and billing of controlled substances via telehealth without prior in-person visits.

Another thorny area is group therapy inaccurately billed as individual therapy. Our analysis uncovered more than $500,000 in overpayments to a single provider who was billing group therapy as 60-minute, individual psychotherapy sessions. A comprehensive FWA program can help reduce these potential problems.

Equip your FWA team with anti-fraud technology. Even skilled investigators can fall into a rhythm in which they focus on FWA patterns they already know — which means they may miss some of these newer schemes ushered in during the pandemic. FWA management programs that use artificial intelligence (AI) and machine-learning technology can help investigators proactively identify early warning signs of new types of fraud.

For example, AI and machine learning can help plans not only identify providers billing higher-than-average volumes of services but also clusters of providers in the same geographic area with similarly high volumes. Looking at these clustering trends can help plans identify the costliest schemes, rather than just focusing on the low-hanging fruit.

Make it clear how members can report FWA. Health plans should educate members about how inappropriate billing can affect their out-of-pocket expenses and how they can be the first line of defense against fraud. During routine outreach, plans can remind members to call their member services hotline if they suspect FWA activity based on a provider’s bill.

However, member education has its limits when it comes to fraud prevention. Bad actors often exploit services needed by vulnerable populations, like the elderly or those with substance use disorder who may be less likely to detect or suspect overbilling from providers. Inaccurate charges are also more likely to fly under the radar if members aren’t paying out of pocket for any portion of their services. For these reasons, expertise in uncovering FWA—either in-house or through a partner—can help detect suspicious billing behavior and create safeguards to prevent further financial harm.

Being Proactive with Consumer Engagement and Fraud Prevention

By embracing these strategies, plans will be better positioned for the challenges that lie ahead now that the PHE has ended. Although the redetermination process is still unfolding, taking a proactive approach to member engagement and FWA prevention can help position organizations for better performance while also supporting vulnerable populations.

leah dewey
Leah Dewey

Leah Dewey is Vice President of Clinical and Consumer Engagement Operations at Cotiviti. As an experienced leader in population health, clinical strategy, product development, and value-based outcomes, she drives product value for Cotiviti’s Consumer Engagement and Population Health solutions. Leah is focused on improving healthcare outcomes by leveraging data and insights to drive closure in care gaps, improve consumer quality, and move population health across various cohorts and cultures.

Erin Rutzler
Erin Rutzler

Erin Rutzler is Vice President of Fraud, Waste and Abuse at Cotiviti. In this role, she is responsible for the oversight and strategic direction of Cotiviti’s FWA solution suite. Erin has been integral in the development of Cotiviti’s FWA solutions over the past eight years. Serving as the company’s primary subject matter expert in investigations and FWA for compliance, client training, sales, and marketing activities, she regularly represents the company at industry conferences such as the National Health Care Anti-Fraud Association’s (NHCAA) Annual Training Conference (ATC).