Payment accuracy helps to ensure the appropriate allocation of healthcare dollars — a goal that is in the interest of all system stakeholders. When payers and providers work together to improve payment accuracy on the front end, it creates more appropriate spending within the system, while reducing the administrative burden of reworking claims so that providers can focus more fully on delivering the best care to patients.
Although payment accuracy is a collective effort, providers are in the inherently difficult position of being on the receiving end of claims denials and payment delays, which can cause frustration and, consequently, abrasion, in the payer/provider relationship. But with greater transparency, efficiency and support around the claims review process, the relationship between health plans and their provider networks can become less transactional and more collaborative. Here, we’re highlighting key strategies for healthcare organizations to improve provider relations around the payment accuracy process.
Transparency & Communication
Healthcare silos inhibiting the productive exchange of information have created widespread inefficiencies and fostered mistrust among stakeholders — a phenomenon that is particularly evident in payment accuracy. Without a clinical basis or relevant context as to why certain claims are being targeted — and visibility into the review and recovery process — some degree of friction remains inevitable. Having a formalized process in place, being upfront with providers about what that process entails and providing transparency throughout helps to mitigate misperceptions of intent for less abrasion and more cooperation.
Accuracy in Claims Selection
All told, Medical Group Management Association (MGMA) estimates the average cost of reworking a single claim to be $25, easily adding up to thousands of dollars a month allocated to this activity alone. But the high administrative burden placed on providers has implications that go beyond monetary cost, with research showing a correlation between provider burnout and healthcare quality and safety. It is therefore essential that the claims being selected for a payment accuracy review are those that are most likely to result in an overpayment, so as not to create excessive work. In selecting a payment accuracy solution, here are a few key considerations to ensure efficient and precise claims selection and help mitigate the burden on providers:
- Breadth of claims data and use of sophisticated analytical models
- Use of artificial intelligence and machine learning to continuously improve systems for claims identification and selection
- Expert clinical staff to analyze data in a clinical context for accurate decision-making
Performance Tracking and Management
The ultimate goal of payment accuracy is to prevent improper payments from occurring and eliminate the need for rework. Identifying patterns in billing behavior and working with providers to understand the specific areas in which they may be struggling creates the opportunity to collaborate toward the shared goal of right-first-time billing. Payment accuracy partners that provide contextual insight into provider performance and enable payers to effectively address these areas of struggle are helping to create long-term value for both parties.
Prioritizing Provider Relations in Payment Accuracy
As a trusted partner to more than 300 health plans, HMS understands how vital the provider network is to an organization’s ability to serve its members. Prior to deploying a payment accuracy program, we work closely with each of our payer clients, including provider and network management personnel, to develop a comprehensive strategy encompassing proactive education, ongoing engagement and dedicated support from qualified clinical staff. HMS’ provider relations program includes:
- Dedicated provider relations call center with multilingual personnel trained in first call resolution and available during extended hours
- Interactive and secure online portal allowing 24/7 access to audit information
- Proactive provider education and resources, including webinars and co-branded outreach materials
- Support of qualified clinical staff across a broad range of specialties
- Actionable reporting of provider performance to facilitate long-term improvement
Since the implementation of the program, payers are seeing substantially fewer provider complaints and appeals, enabling greater savings with less abrasion. To learn more about HMS’ provider-friendly solutions, visit hms.com.