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Encouraging Evidence-Based Healthcare with Pre-Payment Integrity


Increasing the practice of evidence-based care is vital to improving the quality and efficiency of care in the U.S. To push more providers to adopt evidence-based medicine, we must reward high-quality patient outcomes - not high volumes.

Despite years of work in the healthcare industry to put new processes and policies in place that aim to drive evidence-based medicine - the practice of clinical decision-making based on the best available evidence generated by research - there are still tons of financial resources put towards care that doesn’t add value or improve outcomes.

According to 2019 research that studied waste in the U.S. healthcare system, the annual cost of over-treatment or low-value care falls between $75 and $102 billion dollars a year. One component of this massive issue is that payment incentives aren’t always aligned to encourage providers to follow evidence-based guidelines.

Increasing the practice of evidence-based care is vital to improving the quality and efficiency of care in the U.S. To push more providers to adopt evidence-based medicine, we must reward high-quality patient outcomes - not high volumes. Attaching payment incentives to patient outcomes and performance could encourage adoption of evidence-based care more broadly. More specifically, doing so prior to the point of payment would help ensure providers are adhering to best practices while enabling payers to avoid unnecessary costs – ultimately improving overall care quality while reducing healthcare waste.

Adjusting current processes with evidence-based guidelines

Payment integrity is pivotal for provider organizations to function at high efficiency and maintain sustainable operations in the immediate and long-term. With enhanced pre-payment processes, early detection of inaccurate or improper billing results in fast savings and waste avoidance, substantially diminishing downstream administrative cost invested in recovering these overpayments.

By integrating evidence-based guidelines with pre-pay payment integrity protocols, organizations can be confident not only that claims are being billed and paid appropriately, but that patients will receive high-value care. Implementing guidelines also helps to incentivize providers to deliver services in the context of the pathway of care. Care pathways, which are developed to manage patient care, improve quality, reduce variation, and increase the efficient utilization of healthcare, provide a mechanism for integrating evidence-based medicine into clinical practice.

DEXA scans, for instance, can serve as a clear depiction of a scenario in which using pre-payment review processes helps avoid low value care payments. Current guidelines recommend that DEXA scans, which screen for osteoporosis and assess treatment effectiveness, are not performed more often than every two years. With pre-pay review and editing, payers can avoid paying for low value services, like this example, by identifying and rejecting the claims that vary from frequency guidelines early in the payment process. Integrating these guidelines also educates and motivates organizations to closely adhere to guidelines moving forward by aligning processes with evidence-based practices, like ensuring the appropriate intervals between tests or properly coding procedures.

The continued push for evidence-based healthcare

Increasing the practice of evidence-based care by incentivizing more providers to utilize clinically and scientifically validated methods in decision-making is a primary component in the push to improve the quality, efficiency and costs of healthcare in the U.S. Tying evidence-based care to financial incentives, in addition to implementing a pre-payment analytics program, can help organizations avoid improper payments and the time-consuming process it takes to recover medical bills that have been paid improperly. By encouraging healthcare practices that are based in research-generated evidence, we are on our way to a better healthcare system for all.

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