Joining Forces: How to Strengthen Payer/Provider Relationships

Payers and providers are an essential part of the U.S. healthcare system and share a focus on what is best for patients. So, to provide the best care, they must work together. However, this alignment must occur within an increasingly complex environment, which now includes President Trump’s newest Executive Order. [1]

Published in June of 2019, this government directive calls for transparency of price and quality in U.S. healthcare. The new requirements put another extensive regulatory to-do list on the shoulders of both payers and providers. These complications are in addition to the existing challenges and barriers in payer/provider relationships that span clinical, economic, and administrative areas. How can this newest regulation fix existing issues?

The Need for Change in U.S. Healthcare

Payers and providers must collaborate and use their resources to meet goals that benefit all parties - patients included. Unfortunately, statistics highlight the financial waste and challenges that exist within the healthcare sector and speak to the undeniable need for change.

For example, Newsweek [2] estimates that there is more than $1 trillion in wasteful healthcare expenditures annually. Next, add to that figure a high payment error rate [3] that wastes billions, and as much as $210 billion [4] in excessive medical costs related to payer/provider interactions. Both parties recognize the problems and are calling for changes.

A Modern Approach to Utilization Management that Cuts Administrative Waste

A useful utilization management (UM) process is one that combats administrative waste that currently exists in payer/provider relations. A focus on strengthening and streamlining cooperation, rather than competition between the involved parties, is essential.

A modern take on pre-authorization is the optimal solution as many doctors see traditional UM as cumbersome and extra work. Specifically, the answer lies in reducing discrepancies between insurance agencies and health care providers, which has the potential to reduce costs. [5]

Systems that feature more efficient processes for payments and data processing can do exactly that. Zelis Payments (ZP) - a top healthcare payments technology company that focuses on providing value-based customer experiences -- created a system that’s an example of effective processing.

This type of integration within the American healthcare system is capable of lowering admin costs and improving decision-making.

What Does Effective Payer/Provider Processing Look Like?

Meeting in the middle at a shared, easy-to-comprehend, and customizable payment processing system is the way to rethink UM processes. Payers and providers can communicate well within a model based on software that offers the best for both parties and simplifies collaboration between them, despite the complex environment. Zelis Payments offers solution-based software designed to simplify how payers provide payments to providers and increase accuracy.

The payment system receives payments 20 days faster than checks, which, in turn, accelerates secondary filing and patient collections. Furthermore, a well-organized solution like this one can reduce labor costs and improve both accuracy and productivity.

Moreover, with Zelis Payments, providers can see payments and claims at a glance in their secure portal at any time of day. Providers can also receive payments from multiple payers.

Structuring Collaborations Under the HIPAA

Of course, payer/provider relations must comply with the 1996 HIPAA rules [6] for the adoption and use of electronic standards. In addition to complying with HIPAA’s regulations to protect the use and disclosure of sensitive personal and health information, Zelis Payments aligns with HIPPA’s goals to eliminate waste and inefficient processes in healthcare.

While the adoption of new systems can be slow, it has the potential to streamline core business processes across the entire U.S. healthcare system. The benefits aren’t small either.

Adapting waste-reducing platforms, such as Zelis Payments, has the potential to significantly lower the $31 billion [7] in standard business transactions that providers spend yearly in interactions with payers. It’s possible to see additional savings of $11.2 billion [8] annually by moving to more modern transactions.

Finally, Zelis Payments offers full integration for payers and providers using aggregated, errorless 835 documents. This combination removes any money wasted on errors in missed fields or incorrectly filled out 835s. The company even offers electronic remittance advice and related EDI support to help users operate the system to its fullest.

Concluding Words on Joining Forces

In summary, a collaborative payer/provider relationship using an efficient payment system like Zelis Payments has several benefits for America’s healthcare system. Among the chief advantages are its ability to reduce administrative costs for the involved parties and to provide smoother and faster business processing.

Furthermore, healthcare payers and providers who embrace quality software solutions like this one can stay current amid increasing demands, including the newest Government Executive Order.

On a larger scale, when processes have an optimal organization - as demonstrated above - it moves everyone toward the goal of smoother operations, fewer wasteful financial costs, and better patient care. The ability to improve payer/provider relations is within reach and stands to benefit all involved parties.

[1] www.whitehouse.gov/presidential-actions/executive-order-improving-price-quality-transparency-american-healthcare-put-patients-first/

[2] www.newsweek.com/us-wastes-25-healthcares-spending-1463576

[3] publicintegrity.org/health/fraud-and-billing-mistakes-cost-medicare-and-taxpayers-tens-of-billions-last-year/

[4] www.hcca-info.org/Portals/0/PDFs/Resources/Conference_Handouts/Compliance_Institute/2010/P8handout6.pdf

[5] https://abcnews.go.com/US/quarter-us-healthcare-spending-waste-report/story?id=66371897

[6] www.hhs.gov/hipaa/for-professionals/privacy/laws-regulations/index.html

[7] www.ncbi.nlm.nih.gov/pubmed/19443477

[8] www.aha.org/news/headline/2018-06-15-report-fully-adopting-transactions-standards-could-save-112-billion-year

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