How Suppliers Can Navigate Today’s Payor Landscape – 3 Insights


The operational and financial complexity of health care delivery can create tensions between payers and providers. This tension can be exacerbated due to regulations and the implementation of underperforming technologies.

During Becker’s 6th Annual Health IT + Revenue Cycle Conference, Ensemble Health Partners sponsored a virtual panel discussion focused on some of the top payment issues and tensions between payers and providers. The Ensemble team, which included Jim Gaffney, Chief Strategy Officer, and Samantha Timpone, General Counsel, spoke with revenue cycle leaders from across the country about payment challenges and discussed actions and solutions. potential.

Three insights:

1. Rapid policy updates and regulatory changes can be overwhelming. Ensemble has tracked and documented over 46,000 payer updates in 2021 alone. These include updates regarding the No Surprises Act, dealing with long cases of COVID-19, without eliminating the patient list. hospitalized only and price transparency.

A CEO of a southern health system expressed concern about the growing number of requests for price breakdowns. “Payers are now asking for a breakdown of our prices and how they compare to the market,” he said. “We’re in a rural community, but if a hospital sits between two metropolitan areas, that fee structure is a bit higher than most rural hospitals in the state. It’s a sense of unease that could put us at a disadvantage. ” This healthcare system turned to its state hospital association and appealed to the state to help it respond.

Mr. Gaffney stressed that COVID policy updates did not necessarily provide relief to suppliers. “At the start of the pandemic, there seemed to be a good faith effort to alleviate much of the administrative burden related to admissions notices, authorizations and other technical details that could lead to denial of refunds,” he said. he declared. “However, many were very temporary in nature and effective only during the period when the volume was down in hospitals.”

“When volumes increased and intensive care units filled up, these changes were no longer in effect,” he added. “It seemed spurious and didn’t help providers much.”

Ms. Timpone suggested that vendors prioritize strategies that will have the greatest impact by having an internal team or external partner who can stay on top of regulatory changes. In addition, she encouraged providers to work with state legislators to resolve regulatory issues.

2. Payment integrity technology promises to save payers money, but may increase rejections.

Payors’ investment in fraud detection and payment integrity solutions is expected to increase by 30% by 2025. Payors are focused on acquiring and developing internal strategies to reduce near misses. of $ 170 billion spent on incorrect claims and payments each year. Anthem handles roughly 85% of payment integrity activities in-house, and partners with dozens of external vendors to cover the rest. Optum has acquired Equian and Change Healthcare and estimates cost savings of $ 326 billion from improved capabilities. (According to research from Guggenheim Securities cited by Ensemble Health Partners.)

The main payment integrity solutions that payers leverage:

  • Editing claims: a variety of capabilities ranging from simple rules to complex algorithms
  • Clinical validation: typically clinical coding teams to ensure diagnoses are justified
  • Inpatient Claims Review: Systematic Review and Assessment of Provider Claims
  • Fraud, waste, abuse: predictive analytics are increasingly common
  • Subrogation: claims for compensation for injuries are increasingly processed upstream thanks to specific rules

“In some cases, they literally scan thousands of items to take charges that would tip a vendor into a stop loss or other similar activity,” Gaffney said. “So they use this technology a lot… to find areas of weakness that can get the money back. It’s a really big market there.” According to Ensemble, the number of fraud detection and payment integrity solutions is expected to increase by 30% by 2025.

Ms. Timpone encouraged vendors to fight back in these situations, emphasizing that clinical factors are not taken into account with these automated solutions. “They use the software to rule out diagnoses, which is a clinical determination,” she explained. “Under many laws, this must be done by a physician who specializes in the area of ​​practice for which the patient was primarily treated. Vendors can successfully assert that software systems are not doctors.

3. Payers redirect care to less expensive facilities.

Payers recently released a number of policies to reorient patient care with the goal of directing patients to treatment outside of a hospital setting. In their attempts to do so, payers ignore pre-existing contracts with providers and complicate the patient experience and pre-authorization processes. These policies make it increasingly difficult for providers to deliver exceptional patient experiences without negatively impacting their outcomes. For example, UnitedHealth Group (UHG) recently published an article aimed at plans, members and their caregivers encouraging “commercially uncomplicated insured persons” with employer coverage to seek treatment for common outpatient procedures in hospitals. ASC versus a hospital.

Tips for tackling pressure from payers

  • Know what you’re up against
    • Have a strategy to cut the noise of the thousands of updates to get the ones that have the most impact
    • Identify internal SMEs or partners who can stay abreast of regulatory developments
    • Understand the contractual implications
  • Leverage volume to your advantage
    • Submit aggregate disputes that reflect the impact of payers’ policies
    • Engage the state government if necessary
    • Submit bulk sample to government agencies in complaints to show the volume of patient care impacted
  • Be an active advocate
    • Take advantage of notice and comment periods for regulatory changes
    • Work with state legislatures and administrative entities to push back payers policies

A simple knowledge and understanding of the landscape surrounding payers’ issues, regulatory changes and growing challenges in the healthcare industry can provide providers with the knowledge they need to obtain adequate reimbursement.

To learn more about the event, click here.


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