Contention over claims and contracts can cause the payer provider relationship to become strained. Despite improvements in how insurers and physicians collaborate, their relationships are often stymied by a lack of trust. However, adopting these six strategies can help insurers and providers build credibility, making the claims process easier to navigate.
Create a clear contract
Since the contract between providers and payers is the backbone of their relationship, it's essential to have the terms of this agreement clearly spelled out. Later, both parties can easily refer to the rules when a conflict arises. Contract policies should be favorable to both sides. Providers, though, should be on the lookout for "evergreen clauses," provisions that allow for automatic renewal unless the provider notifies the payer ahead of time to terminate the contract upon its expiration. Read everything carefully before signing to avoid confusion.
Consider all stakeholders
To help payers and providers establish a contract that fairly reflects their best interests, industry leaders recommend that they align their objectives with a common purpose, which is ultimately to serve patients. The terms they agree to will be based on trends within their local market, but rules should be amenable to payers while not creating undue administrative burdens for providers. Both entities should work together to create criteria for determining when treatments are medically necessary. Considering all stakeholders-- including patients-- limits utilization costs and encourages collaboration.
Partner with other healthcare entities
Hospitals can collaborate with other health organizations, such as home healthcare providers, to better coordinate care, which can help control costs. Forming cooperatives can mitigate financial risks for both parties. Partnerships allow for ongoing monitoring and interventions that may reduce the likelihood of readmissions or more frequent visits to a provider.
Payers and providers should meet periodically, even if there are no claim disputes to discuss. Planning lunches or coffee breaks can be especially helpful at the beginning of the payer provider relationship, as it promotes transparency and trust. Eventually, both parties may decide to meet less frequently, but should still touch base occasionally to be sure they're on the same page. When getting together to settle a dispute, an agenda should be prepared in advance so payers have time to do the necessary research beforehand.
High-quality practice management software streamlines claims processing. By minimizing the amount of manual data entry required, digital tools ensure improved data integrity and therefore a higher volume of clean claims. Before claims are submitted, the software can identify coding errors or other discrepancies so they can be corrected before they result in denials. On the payer side, providing portals through which providers can check the status of claims saves time and minimizes the frustration of tracking claims manually.
Conduct an internal review
When handling denials, hospitals should not automatically assume that the payer is at fault. Claims-management personnel should conduct a root-cause analysis to determine the percentage of claims that have to be appealed and the underlying reasons for rejected claims. This is another area where technology is an incredible asset in helping hospitals and health organizations identify patterns of recurring problems.
Following these tips will strengthen the payer provider relationship, making the transition to value-based care more straightforward on both sides.