Podcast: Melanie Combs-Dyer, Director of Innovation at Mettle Solutions

After spending 30 years at CMS, launching her own consulting company, and becoming the Director of Innovation at Mettle Solutions, Melanie Combs-Dyer is an expert in the communication streams between clinicians, healthcare payors, and patients. We spoke with her about the burden of provider credentialing, tension points within the payor/provider relationship, and how FHIR can change the face of healthcare interoperability in the coming years.

Below are a few highlights from our interview, but be sure to listen and subscribe to The Patient's Journey podcast, linked at the bottom of the page.

Where have you come across tension points in the payor/provider relationship?

Well, I think I'm getting more sensitive to just how overwhelming it is for providers to have to deal with so many different payors. I am most familiar with the Medicare fee-for-service program, since that's where I spent 30 years helping run that program for the Centers for Medicare and Medicaid Services.

But by golly, there are a lot of other payers that are out there. These poor providers have to deal with so many of them, and the number keeps increasing every year. It seems like it must be overwhelming for providers to have to deal with all that. Physicians must be so frustrated by the huge number of people that are calling them every day, needing something, needing them to do something for their patient.

When I was at CMS, I don’t think I was as sensitive to that as I probably could have seen or should have been. Now that I'm on the outside, I can really see that it's just it must be just overwhelming for providers.

We know that upwards of a trillion dollars every year in US healthcare is wasted due to fraud, inefficiencies, and more. How do you begin thinking about how to tackle a problem so big?

I think that one part of the solution has to do with keeping the bad players out to begin with or being able to take them out of the system once they’re identified.

Sometimes the staff at CMS that work in the provider enrollment area lack the tools to kick out bad players who commit fraud, etc. The Medicare statute, as it’s written, basically allows all comers. Whether you’re a DME provider, imaging company, home health company, or otherwise. Medicare and the Medicare fee-for-service program has to take them, which is unlike some of the managed care organizations that can set their own network.

I believe that Medicare oftentimes needs stronger tools and regulations to give them the authority to kick out the bad guys. We want to strike a balance between reducing provider burden but also keep enough standards in place so that we’re not letting in bad actors. We have to get those enrollment rules exactly right, which is a tough position to be in.

Another part of it, is that we should simplify the rules for Medicare fee-for-service. Sometimes it’s hard for providers to remember specific documentation needed for a specific payor. So a lot of folks in the FHIR (Fast Healthcare Interoperability Resources) community have been developing solutions to try and help solve that particular problem. The goal is to show the provider the documentation and coverage before a service is ordered, as opposed to today’s pay-and-chase model. This may help reduce some of the lack of appropriate documentation which is driving some of the improper Medicare fee-for-service program payments.

How do you see us keeping fraudulent players out of the system in the first place?  

It's been very interesting over the last few years to watch how some of the big data companies have proposed solutions that can help to identify bad actors in the system. Once a bad actor has been convicted of fraud, data can help us figure out their business associates, relatives, etc. Big data can then share that with the insurance companies so they can be on the lookout for falsified claims coming from, for example, the bad guys’ business associate. That’s been extremely interesting to watch in recent years.

I also think that getting rid of faxing and adopting new communication technologies between provider and payor will be helpful. Let’s take prior authorization, for example. New technology is coming out which can move that prior authorization request directly out of the jar and to the payer very quickly in a structured way: not a picture of the medical record, not a PDF that gets uploaded to a website or that gets faxed in, but structured and tagged information that can generate authorization instantly.

Let’s talk about provider credentialing. We oftentimes see clients who are relying on so much messy paperwork, filing cabinets, and more to try to accurately track credentialing. From your experience, is this typical/how does the credentialing process typically work?

Actually, before I started at CMS I worked for the State of Maryland in the Department of Licensure. Nurses like me were sent out to various hospitals across the state of Maryland to review in-person various credentialing files: double-checking that physicians had gone to certain medical schools, had the appropriate credentials, etc. I believe there has been some advancement in credentialing since I worked there, but I’m afraid there’s still an awful lot of faxes and photocopies in the credentialing process. And each hospital is doing the same complicated process for each physician or employee.

It would be ideas if our country could get to the place where the credentialing process was more centralized. If there were more coordination and centralization, you might be able to reduce the significant provider burden. So that’s something that I’d really like to see change in the next few years.

Any reading recommendations for your colleagues?

I’m not sure that I would recommend a specific book, but I would recommend a category of podcast. Coming out of this most recent election, we can see that our country is very divided. We really need to find a way in our country to be less tribal, less about R vs D. We need to find the more centrist solutions.

I would encourage listeners to try to find podcasts that are out of their traditional political tribe, to hopefully move us citizens more toward the center and toward solid solutions in the middle of the road for issues facing our country.

To listen to more from our interview with Melanie Combs-Dyer, click the Apple Podcasts link below:

‎The Patient's Journey on Apple Podcasts

‎Health & Fitness · 2021