Payment integrity programs aim to ensure accurate claims processing, adherence to contractual rates, and compliance with payment rules. While these efforts are crucial for sustaining the financial health of healthcare systems and ensuring that patients receive appropriate care, they can easily create friction between payers and providers. This friction arises from disputes over claim denials and the administrative burden with claims adjudication.
Providers are under pressure, with inflation lingering at 3.3% and continuing to drive increased hospital costs. What’s more, cuts to Medicare physician payment rates are making running a practice more unsustainable for physicians and driving the rise in hospital-employed physicians, which now stands at 77.6%, a 25.8%-increase from a decade ago. On top of these factors, 7% of physicians have left the workforce, primarily led by internal medicine and family practice. Healthcare organizations need to make up shortfalls elsewhere somewhere, such as potentially billing more on claims to help cover rising costs.
As payment integrity becomes increasingly important due to increased healthcare spending and complexity in billing processes, it must prioritize reducing provider abrasion to improve billing practices and relationships between health plans and providers.
"When we're talking about abrasion, we're referring to both the practical and emotional aspects of misunderstanding and disagreement by healthcare providers with the payment integrity efforts of payer organizations," says Timothy Garrett, MD, chief medical officer at Zelis and a former emergency physician.
"If you think about the practical effect of that payment integrity effort, it's the time and the effort that is required," he continues. "For providers, that time and effort translates into money being spent. Of course, the emotional aspect is the frustration that results from that misunderstanding and disagreement."
For example, a provider may be unclear about why a modification was made to a claim or disagree with a decision after a payer's review of the claim and medical records. Resolving claim disputes means less time for patient care and lost revenue for the practice; likewise, it places additional strain on a workforce experiencing widespread shortages and burnout.
A core strategy to mitigate provider abrasion involves improving communication around claim denials and payment policies. Readily available policies prevent surprises.
"A clear explanation of a denial can help a provider to avoid the same coding and billing error in the future," Garrett explains. "Beyond that, payers who have readily accessible and very clear payment policies help the provider know what to expect in their claims processing."
Another key strategy to complement communication is a human touch. While artificial intelligence has a role in healthcare today and great potential for tomorrow, it will take time for technology to grasp the complexity of medicine and coding.
"You hear a lot of talk these days about artificial intelligence and how that is helping in a lot of different areas," says Garrett. "This is true, but modern medicine is complex and medical coding can be even more complicated. There are more than 70,000 diagnosis codes in ICD-10. There are more than 72,000 procedure codes in ICD-10 and more than 11,000 CPT codes. Codes are added and rules changed every year."
Payment integrity demands human expertise and human-to-human interactions to address provider abrasion effectively.
"It takes clinicians with extensive coding knowledge and coders with deep clinical knowledge to explain the complex payment integrity decisions made," he argues. "Just as importantly, healthcare providers want to know that their perspective is being heard and understood, and artificial intelligence engines can't do that."
Another effective approach to mitigating provider abrasion is customizing payment integrity solutions to meet the unique needs of different providers and patient populations.
"Unique providers and patient populations require unique solutions," Garrett observes. "For example, a payer may allow claims from a specific provider who is giving extensive, cutting-edge treatment that might be considered investigational and thus might not be allowed on a claim from another provider. It's really important for payer organizations to be able to handle situations like this in a custom manner. Not all payment integrity partner organizations offer the ability for payers to customize solutions."
Clear communication, human expertise, and customized solutions stand out as key approaches to enhancing the relationship between healthcare providers and payer organizations. Choosing the right payment integrity partner helps reinforce and strengthen a payer's payment integrity efforts.
"Many payer organizations are already doing at least some payment integrity," says Garrett. "We at Zelis hear from payers all the time asking for help in developing a strategy for payment integrity solutions. Many times, it's identifying areas in which their internal staff can have the most impact. That's especially true when we're talking about direct communication with providers. That's many times the best use of internal staff from payer organizations."
As the healthcare industry evolves, these strategies will ensure that payment integrity efforts are efficient and provider-friendly, ultimately leading to better patient outcomes.
"It does require collaboration between payers and providers. By keeping the patient's interest at heart, both parties can align their efforts to optimize outcomes," Garrett concludes.
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Zelis is modernizing the healthcare financial experience by providing a connected platform that bridges the gaps and aligns interests across payers, providers, and healthcare consumers. Zelis sees across the system to identify, optimize, and solve problems holistically with technology built by healthcare experts. To learn about our payment integrity solutions, click here.
