Healthcare is painfully confusing sometimes. Not just for the consumers but for payers and providers equally. We’re all aware of the obvious challenges: Figuring out how to bring a digital-first world to healthcare, the increasing prevalence of high-cost claims, and the skyrocketing healthcare costs.
All these problems have created mounting tension between payers and providers. And though it’s not a new story by any stretch, I do believe it’s one we as an industry must work harder to resolve.
We can at minimum acknowledge there are two sides to every story. Payers are often asked to pay for care without understanding how or why a fee was charged, leading to higher costs and operational inefficiencies. Meanwhile, providers are frustrated that they aren’t getting paid for the services they feel are essential – and often feel restricted by the complex contract terms. Both cause providers and payers to disagree on a rational cost of care.
All that impacts the consumer experience, and it’s worth noting that our ultimate goal is the same: Providing consumers with the best care to promote a healthy population.
Our team launched a new pricing solution recently, In-Network Pricing and Contract Modeling, and that got me thinking about how we can use claims pricing as an avenue to enhance provider relationships. To that end, here are four ways payers can reduce provider abrasion through stronger communications:
Offer a fully transparent process trail
So much provider abrasion stems from a simple lack of clarity. Providers need better visibility into how claims are priced. A clear process trail that provides line-by-line transparency into how a claim has been priced and shows the work behind specific formulas and edit logic applied at the claim and line level is essential. This will help minimize provider friction and decrease appeal rates.
Integrate platforms with advanced technology
The role technology plays in healthcare is a hot topic right now, and for good reason. Technology gives payers an avenue to price claims and communicate the outcome to providers faster.
More specifically, when a claims pricing solution integrates into your system – whether via API, EDI, or portal integration – you have quicker turnaround times and less tech overhead. You can reprice contracted claims faster and get providers the information they need sooner.
While technology is not the sole solution and doesn’t negate the need for real people reviewing claims, it can simplify and streamline the process.
Don’t sacrifice your service model
Communicating effectively with providers requires you – the payer – to have an in-depth understanding of provider claims. You need deeper insights and flexible solutions to go into provider negotiations with confidence.
At Zelis, we’ve made our passion for the client experience no secret, but it’s for good reason. Every payer and provider has different needs. Healthcare is not a one-size-fits-all approach, and that means customization and flexibility should be key tenants of claims pricing.
Analysis, loading and managing complex contract terms provide the visibility you need to communicate with providers accurately and knowledgeably.
Support the effort to reduce vendor footprint
A big cause of provider friction is the delay in receiving payments. That’s been especially true the last few months. Even so, it’s not exactly a new problem.
Long term, payers will find uniting their payment and claims pricing solutions under a single vendor can cut down on administrative burden, boost efficiency and fast-track payment delivery.
In today’s evolving healthcare landscape, it isn’t practical to continue using multiple vendors to manage provider payments. Bringing everything under one house helps build a stronger partnership and reduces the complexity in your supply chain.
Think about the different hats you’re wearing every day to manage a vendor for every individual solution. You need to cut back administrative overhead and speed up processes wherever possible to ensure claims are accurate, providers are happy and payments are made quickly.
Clear communication is vital
Strengthening payer-provider relationships shouldn’t be as difficult as it is, yet so often we find ourselves at a loss for how to make an impact.
Communication is at the heart of this. Gaining more understanding into how a claim was priced can alleviate so many of these challenges that it really should be a must for your claims pricing solution.
The Zelis In-Network Pricing & Contract Modeling solution was built on that very premise, and our team has worked hard to provide clients with a fully transparent process trail that shows how each claim is priced. Learn more about it and connect with our team here.
