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Mitigating healthcare challenges through payer/provider communication and collaboration

November 04, 2022
Business Affairs
Lisa Hebert
By Lisa Hebert

The number one goal for concerned interests in the healthcare ecosystem—payers, providers, and patients alike—is optimizing patient care. Oftentimes, however, administrative mazes create confusion and bottlenecks along the way. Whether challenges arise in the transfer of voluminous patient data from one point of contact to the next or occur when processing insurance claims, convoluted workflows can create logistical stress and weaken a patient’s treatment process.

From the standpoint of a patient, imagine you are seeking medical treatment for a chronic condition. In addition to dealing with the physical and emotional tolls that come with the diagnosis, patients often have to face obstacles in securing authorizations and have to deal with strained communication between a doctor and an insurance company. These supplementary tasks create stress and add tension to patients attempting to keep a focus on health improvement; they can adversely affect healing and cause delays in treatment.

In fact, a number of healthcare organizations have reported adding full-time positions specifically to handle prior authorization approvals due to slow responses from payers, help clear up vague language, and secure final approval in a timely manner.

As health organizations increase the development of products centered on the transition to value-based care, provider alignment along with actionable data, becomes critical. An emerging solution to ease these growing demands lies in a technology designed to enhance communications between health plans and providers, increase operational efficiency, lower costs, and improve provider satisfaction.

Paving the way for stronger collaboration between health plans and payers is a technology that offers a secure, multi-payer platform delivering vital clinical—and administrative—data to providers in real time so they can move quickly and easily communicate across multiple health plans.

Membership verification and coverage information
A key benefit offered by this technology is simplified membership verification and transfer of coverage information. On average, 28 eligibility and benefit verifications are required per member every year. If a health insurance company has a member base of 100,000, that’s an estimated 280,000 individual verifications required annually, which will certainly pose a hazard to efficiency and threaten to create logistical bottlenecks and delays in care.

Collaborative platforms help deliver membership verification, insurance coverage information, and payment details—such as copayments, deductibles, and benefit details—to provider offices in real time, reducing the length it takes to verify patient information and expediting care delivery. In addition, these platforms configure and implement plan-specific search criteria, establish default data values, and EDI (Electronic Data Interchange) parameters that best meet health plan and provider needs. By automating the eligibility and benefits workflow, payers can save an estimated $9.8 billion per year.

Streamlining prior authorizations
Another benefit of advanced payer/provider collaboration tech is a streamlined prior authorization process. As medical policy guidelines and standards increase in complexity, this process can become quite burdensome for all parties—payers, providers, and patients alike.

As it stands, only 26% of authorizations are fully electronic, requiring repetitive phone calls and time-consuming paper claims. Shifting these manual processes to a simplified online form with digitized tracking and storing of patient and treatment data consolidates the prior authorization process and allows providers to access the most current information across status updates, approvals, and denials.

In addition, it allows for automatic requests and streamlines applications for the exchange of clinical, financial, and administrative documents in real time. Ultimately, cloud-based solutions simplify the prior authorization process without requiring dramatic changes to provider behavior and payer workflow processes, helping to build trust between payers and providers while optimizing patient care.

Facilitating informed referrals
An additional benefit includes facilitating referrals. Offering detailed referral information—with convenient, secure, and easy online accessibility—enables providers to make more informed referral decisions and help ensure value-based contract success, all while lowering costs through optimizing in-network referrals and reducing data leakage.

On average, one in three patients is referred to a specialist each year. Collaborative solutions improve productivity and reduce administrative costs by responding to critical referral requests from provider offices in real-time, dramatically reducing customer service phone calls and guiding patients to the best specialist at the most affordable cost.

This solution allows administrative staff to navigate complex sub-networks, including identifying benefits tiers, matching patients with specialists in their targeted network, and offering preferred provider lists—which are especially beneficial to health plans developing narrow network programs that require advanced provider steerage.

End-to-end electronic collaboration between payers and providers ultimately increases workflow efficiencies by providing timely, user-friendly, and intuitive resources across the healthcare spectrum. When communication is clear between these key players, it leads to more accurate and prompt results for the patient. The partnership attained by a simplified, collaborative portal eliminates unnecessary—and often manual—workloads, conserving resources and increasing savings on behalf of all parties.

About the author: Lisa Hebert is the Senior Director of Product Management at NantHealth, where she leads the product management team for NaviNet, a leading payer-provider collaboration and engagement platform. Under her leadership, Hebert has expanded the product portfolio and introduced new capabilities that enhance and promote greater administrative efficiencies for payers and providers. Prior to joining NantHealth in 2016, Hebert was the Director of Product Management for Highroads, Inc., a start-up focused on payer SaaS offerings to enable sales and marketing teams self-service workflows aimed at speeding up the sales cycle and meeting ACA mandates for timely and accurate plan benefit information. Over her 20-year career, Hebert has held several product and project management roles in the healthcare industry, including Tufts Health Plan, Best Doctors (now Teledoc), and Caritas Christi Healthcare. Hebert holds a Bachelor of Arts degree in Communications from Westfield State University.

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