Much friction exists in healthcare between all parties — patients, providers and payers. I covered the impacts this friction has on patients and providers in other posts — this time, I want to focus on the challenges faced by the payer. A primary driver of payment friction between payer and providers is denials. Denial write-off adjustments average 3%–4% of net revenue which equates to $262 billion annually in initially denied claims for providers.1
Lack of trust: There’s 900+ payers with different plans and rules in our healthcare market today. Not only does this make it confusing to navigate from a benefits and payment standpoint, but it can make it hard to build trust with patients and providers. Despite the narrative positioning insurance companies as highly profitable organizations, a mandated 80% must be spent on care and quality improvements. When profits exceed these number, funds must be returned to the subscribers paying the premium.2
Best practice tip: Transparent pricing — including information on the payer-specific negotiated rate — helps remove any confusion about rates and costs. When patients and providers are able to easily view and understand their payment responsibilities, it makes for a more positive experience.
Inefficient data management processes: Health plans exist to distribute risk across a population in an effort to reduce overall costs. To be able to provide the best services at the most affordable costs, a streamlined data management process is essential. This can be difficult to do, especially when information is siloed, disparate or not well managed.
Best practice tip: Put comprehensive data management strategies in place, and be sure the data you’re using is industry-leading and comes from a trusted, accurate source. Invest in the right tools and technology to enhance your strategies.
Healthcare literacy: Navigating the healthcare system can be confusing for patients, as they often don’t know where to go for the best level of care, how much their payment responsibility will be, and/or if the services rendered will be covered by insurance. Without having a better understanding of all of this, overall satisfaction can suffer. Payers, in many cases, are the best source of information on costs and coverage, but they’re often not consulted.
Best practice tip: Find the best way to proactively reach out to patients (via their preferred method) about their care and its costs. Just as consistent communication with patients is important, it’s equally important to maintain positive relationships with providers. By collaborating with both groups, healthcare consumers can feel more engaged and empowered in their care decisions.
Risk and engagement: Unmet social needs can affect member health, and drive higher costs and utilization of healthcare services.3 Socioeconomic data at the individual and community-level can help inform innovative wellness programs and interventions, and improve organizational efficiencies. With affordable care being top of mind for patients and providers, social determinants of health (SDOH) have become a worthwhile strategy for payers to more carefully consider and implement.
Best practice tip: Consider identifying a technology partner that specializes in socioeconomic data aggregation. This will help produce strong risk mitigation strategies and ultimately improve overall health outcomes.
Patient engagement: For actionable insights to be possible, it’s imperative to have accurate member identity information available. With right-party contact data, you’re able to reach the right person on the first attempt via their preferred method (phone, mail or electronically), thus improving member safety and engagement while also reducing the cost of unnecessary visits.
Best practice tip: Implement a member matching and/or identity solution to validate you’re using the most up-to-date member information. A good starting point for ensuing data hygiene is to update duplicate or mismatched contact information.