Long Description
Health Care Payment Nexus
Collaborate for collective success
The current health care payment process is unsustainable. Alone, payers and providers are unable to reduce the $200 billion in annual administrative waste.1
The median 350‐bed hospital denial write‐offs have increased from $3.9 million in 2011 to $7 million in 2017.2
Payer admin cost of claims work is equal to 1 percent of paid claims.3
Shared pain points offer opportunity to reinvent the payment process. Alignment and collaboration can reduce inefficiencies and may ultimately lead to a denial‐free future.
Source notes
1. Institute of Medicine of the National Academies. The Best Care at Lower Cost: The Path to Continuously Learning Health Care in America. Washington, DC: National Academies Press; 2013.
2. 2017 Advisory Board Research: 10 Findings from the 2017 Hospital Revenue Cycle Benchmarking Survey.
3. Optum analysis.
Pain points
Pain point 1
Lack of access to complete benefit data hinders the ability to accurately identify patient out‐of‐pocket costs, coordination of benefits and payer liabilities. The result is confusion over cost of care and administrative costs.
This occurs at the pre‐service stage, as an aspect of eligibility and benefits including insurance verification.
Pain point 2
Confusion about which services require prior authorization and how to obtain retroactive authorization results in patients not receiving timely and appropriate care.
This occurs pre‐service and at service in regard to prior authorization. It includes insurance verification, authorization and medical necessity, and documentation and coding.
Pain point 3
Exchange of incomplete and delayed clinical documentation and coding does not accurately support services rendered and can skew reimbursement and quality scores.
This occurs at service as an aspect of coding.
Pain point 4
Claims submissions with inaccurate, incomplete or missing information require costly follow‐up and re‐work.
This occurs post‐service during claims processing as part of billing and adjudication.
Pain point 5
Inability to determine root cause of denials leads to error re‐occurrences, appeals and costly feedback circles.
This occurs post‐service as part of denials and denials management.
Solutions
Solution 1
Upfront exchange of accurate insurance coverage and eligibility data allows both parties to know financial responsibility, enabling patients to make financial arrangements pre‐service.
This occurs at the pre‐service stage, as an aspect of eligibility and benefits including insurance verification.
Solution 2
Coordination before and during care delivery reduces care variation, improves policy compliance and offers opportunity to influence site of service.
This occurs pre‐service and at service in regard to prior authorization. It includes insurance verification, authorization and medical necessity, and documentation and coding.
Solution 3
Alignment of accessible and transparent source/reference data to support complete documentation and accurate billing.
This occurs at service as an aspect of documentation and coding.
Solution 4
Mutual agreement on documentation guidelines, payer‐specific rules and contractual terms can be reached prior to claim submission.
This occurs post‐service during claims processing as part of billing and adjudication.
Solution 5
Improved communication, education and shared data analysis allows for upfront root‐cause discovery and resolution.
This occurs post‐service as part of denials and denials management.
Payer and provider collaboration benefits everyone.
How to start collaborating:
- Shift payment processes from post‐service to pre‐service
- Transparently share rules and data
- Transition from transactional relationships to strategic partnerships
Payer benefits
- Reduces risk of claims overpayment
- Lowers costs for payment integrity
- Boosts provider, patient and member satisfaction
- Improves provider contract rates
- Enhances ability to influence utilization
Patient benefits
- Educates and empowers
- Increases awareness of financial responsibility
- Ensures clear and timely correspondence from payers and providers
- Prevents delayed access to care
- Provides peace of mind about coverage
Provider benefits
- Accelerates payment
- Reduces denials and write‐offs
- Cuts administrative costs
- Improves patient satisfaction
- Increases clarity on payment rules and regulations
