28 Jun IMPROVING PAYMENT INTEGRITY AND REDUCING ABRASION
Payment integrity programs are designed to ensure accurate claims processing, adherence to contractual rates, and compliance with payment rules. These efforts are vital for maintaining the financial stability of healthcare systems and ensuring that patients receive proper care. However, they can create friction between payers and providers, stemming from disputes over claim denials, reduced reimbursements, and the administrative burden associated with claims adjudication.
Providers are under significant pressure, with inflation at 3.3% driving up hospital costs. Additionally, cuts to Medicare physician payment rates are making it increasingly challenging for physicians to sustain their practices, contributing to a rise in hospital-employed physicians, now at 77.6%, a 25.8% increase from a decade ago.
Compounding these challenges, 7% of physicians have left the workforce, primarily from internal medicine and family practice. Healthcare organizations must find ways to compensate for these shortfalls, with increased billing on claims being one potential method to recoup costs. Unfortunately, this can heighten tensions between payers and providers.
As payment integrity becomes more crucial due to rising healthcare spending and complex billing processes, it must focus on reducing provider abrasion to improve billing practices and relationships between health plans and providers.
One core strategy to reduce provider abrasion is improving communication around claim denials and payment policies. Readily available policies can prevent surprises by helping providers know what to expect when processing claims.
The next key strategy is communication coupled with the human element. While the role of artificial intelligence (AI) in healthcare is a hot topic at the moment, it will take time for technology to fully understand the complexity of medicine and coding. Codes and rules are constantly changing and being added. Payment integrity requires human expertise and interactions to effectively address provider abrasion. AI is not able to explain complex payment integrity decisions like clinicians with extensive coding knowledge and coders with deep clinical knowledge.
Customizing payment integrity solutions to meet the unique needs of different providers and patient populations is another effective approach. In some cases, a payer might allow claims from a specific provider offering cutting-edge treatment considered investigational, which might not be allowed from another provider. It’s important for payer organizations to handle such situations in a custom manner.
Another key component of payment integrity programs is the adoption of modern technology solutions that utilize accurate and usable eligibility data in coordinating benefits. When Medicaid payers do not have access to clean eligibility data, it can cause abrasion at the pharmacy for program beneficiaries and lead to improper payments. Accurate eligibility data significantly helps to properly adjudicate claims, saves valuable program resources, and, most importantly, ensures that members receive the care and medications they need.
Clear communication, human expertise, and customized solutions are key to enhancing the relationship between healthcare providers and payer organizations. The adoption of modern technology solutions and clean, actionable data is another key tool for reducing abrasion and honing payment integrity. As the healthcare industry evolves, these strategies and data solutions will ensure efficient payment integrity efforts, ultimately leading to better patient outcomes.