Payer-Provider Synergy: Aligning at the Fulcrum Points

Krithika Srivats, SVP, Clinical Practice and Products, Sagility; Jason Besterfeldt, SVP, Sagility

In recent years, the health care industry has experienced unprecedented change. Tech enablement, strategic service offerings, value-based care initiatives, and data sharing mandates have converged with the goal of creating a system that is member/patient-centered and outcomes-based, while also lowering the overall cost of care. It is now widely understood that the member/patient is increasingly demanding better and more transparent payer-provider collaboration. In fact, 83% of patients in a recent Physicians Foundation survey called for better communication between physicians and health insurance plans.

Payer-provider collaboration represents a crucial opportunity to bridge the gap between those who provide care and those who finance it. This collaboration paves the way to improved outcomes founded on data sharing and aligned strategies. While there are touchpoints set up for synergies all along the lifecycle, there are three crucial areas of both challenge and opportunity for payer-provider collaboration. With actionable strategies, providers and payers can improve collaboration with immediate benefit to payer, provider, and member/patient: prior authorizations, member/patient experience, and clinical denials.

Opportunities for the Payer: Prior Authorizations

Traditionally, the prior authorization step has been viewed as cumbersome, with high administrative costs running into billions of dollars across the healthcare sector. The new Centers for Medicare & Medicaid Services (CMS) mandates for interoperability and better transparency can help improve concurrence in the prior authorization objectives. The new regulation aims to shorten the timeline for the prior authorization process to immediate or as little as 72 hours for individuals who get their health insurance through Medicare Advantage, Medicaid, or a Qualified Health Plan on the exchanges. Today’s prior authorization automation aims for utilization management (UM) “right cost” and “right outcome” for payers. This intelligent technology can render clinically appropriate real-time decisions for providers and simultaneously reduce cost per authorizations. For health plans, this high-impact prior authorization ups the ante with an analytical approach to flag clinical decisions that need priority nurse review. The algorithmic decision support can identify high dollar clinical usage patterns, fraud, waste, and abuse (FWA) patterns and current procedural terminology (CPT) conversion/alternative treatment.

Health care services experts with ecosystem capabilities will bring:

• Understanding of payer rules, requirements, timing, and appropriate documentation
• Experienced clinical resources supported by artificial intelligence (AI) workflows to effectively manage process and cost
• Improved provider relations and change of the perception of this process • Simplified communication with the member/patient both before and after the visit, for improved satisfaction

Opportunities for the Member/Patient: Customer Experience

In recent years, the spotlight has been increasingly focused on member/patient experience. A key driver of member/patient satisfaction, as measured by NPS, is how providers and payers manage provider network data and ensure it is accurate and made available in a timely manner. Bridging this gap yields immediate improvements in care delivery and patient satisfaction. 

Collaborating with payers to build an intelligent portal that can automate the exchange of information offers a means to access this low-hanging fruit to improve care and lower costs. Leveraging Council for Affordable Quality Healthcare (CAQH) with intelligent automation (eg, machine learning and AI driven analytics) cuts turnaround time and gives providers the ability to monitor credentialing status in real time and act accordingly.

Examples of payer/provider collaboration to benefit the member/patient include:

• Use of an intelligent portal for more accurate provider credentialing and data reporting, expanding the payers in network and easing provider navigation for the member/patient
• Improved price transparency with greater exchange of financial eligibility
• Enhanced planning with pre-arrival financial counseling and member/patient communication to address:
  • Coverage by insurer
  • Contractual details on how much member/patient is responsible for
  • Financial counseling and payment options

Opportunities for the Provider: Clinical Denials

Regarding reducing clinical denials through improved collaboration, the numbers speak for themselves. A recent Crowe RCA benchmarking analysis found that clinical denials rose to 11% of all claims in 2022, up nearly 8% from 2021.

Through better collaboration, 3 root causes of pre-service and post-service denials can be addressed: technological inefficiency, the shortage of trained clinicians, and the increasing complexity of procedures. The right health care service experts will answer with scalable resources, process ingenuity and tech enablement. Today’s natural language processing (NLP) and AI technology can provide real-time triggers for up coding, unbundling, as well as verify against clinical criteria that need to be documented in the provider notes. Integrating such technology before claims submission as well as the creation of appeals letters.

When appeal letters are automated using NLP and machine learning and combined with a more complete and timely understanding of payer guidelines, the result is lower cost and improved overturn rates. Starting with specialized routing, followed by nurse-assist automation, clinical coding criteria mapping, and finally tech-enabled audits, providers can improve overturn rates from industry standard rates of 35% to over 65%.

In all of these critical point of service areas, healthcare experts with experience, resources, and enablement across both payers and providers can collaborate and bridge gaps. The end result will be improved quality of care and payer-provider relationships, as well as enhanced outcomes for the member-patient.

About the Authors

Krithika Srivats, MSOTR, is Senior Vice President, Clinical Practice and Products at Sagility, a technology enabled, pure-play health care-focused solutions and services provider. Krithika has 25+ years of diverse experience in patient care, strategic disease management in the field of Alzheimer's and related dementias and, as an occupational therapist, has a passion for helping elders live safely at home.

Jason Besterfeldt, Senior Vice President for Sagility, boasts an impressive career spanning nearly 25 years as a senior executive in health care Revenue Cycle. Throughout this extensive tenure, he has collaboratively engaged with various entities, including health systems, hospitals, ASCs, physician groups, payers, and banks. His professional emphasis revolves around strategic resource allocation, prudent technology investment, and the optimization of workflows. This targeted approach has consistently yielded significant benefits for his clients, empowering them to enhance cash reserves, minimize collection costs, and mitigate operational risks.