Payers and providers have learned a new dance — one based on digital tunes, with tasteful accents provided by healthcare technology.
Admittedly, the journey from formidable foes to amicable associates is a bumpy one. However, the only way to achieve a more patient-centric care delivery system is to change old tunes and learn new dance steps. Part of the new healthcare reimbursement playlist must focus on improved payer-provider relationships. This article lays the foundation for improved relationships through stronger mutual respect, collaboration and understanding during health plan audits.
Health plan audits open door to better collaboration — for the patient’s sake
Payer-provider relationships can be mutually beneficial — and when built properly, will help providers get the attention they need in areas affecting direct reimbursement. Moreover, studies show this new model is better for both pocketbook and patient.
One of the largest parts of healthcare reform — and one of the hardest for hospitals and physician practices to manage — is the transition from a fee-for-service model to one that rewards for value. Health plans work diligently to demonstrate value to their members through audits.
A growing number of health plan audits are conducted nationwide to ensure quality care is delivered and patient disease status improves. The most common health plan audits focus on risk adjustment and include: Medicare Advantage Risk Adjustment (MRA), Health Effectiveness Data & Information Set (HEDIS), Medicaid MRA & HEDIS, and Commercial MRA. Through these audits, health plans improve their own financial performance.
Simultaneously, audit findings can be used to educate and proactively guide providers to document better care for their patients. Better documentation yields cleaner clinical data — improving quality rankings and care outcomes for everyone involved: health plans, providers and patients.
Patient health is common goal
On the other side of the equation, in this age of quality ratings needed to justify Medicare payments, health plans need solid, clean data and information, especially in areas of managed care. While patient health is the common goal, clean data is the tool that allows for more fact-based decision-making and allocation of limited resources.
Without clean data to drive caregivers to look for key symptoms, minor complaints could turn into major ones. For example, a diabetic patient mildly complaining of foot pain might end up with untreated diabetic neuropathy, because the diagnosis of diabetes wasn’t properly documented during the first days of a patient encounter.
Accurate patient data helps health plans segregate their patient populations, assign the most effective treatments, and drive optimal clinical outcomes at the lowest possible cost. Full collaboration with providers is essential.
Patient-centric care is built on strong payer-provider relationships. The most powerful tool in building these relationships is clear communication. When requesting data or other information from providers, health plans should:
• Be clear as to why they need the information
• Be sympathetic to the administrative burden their information requests place on providers
• Use consistent verbiage in their requests for information
• Avoid redundant or duplicate requests
Providers also play a key role in ensuring clean, consistent patient information. Providers should become more educated on the reasons for health plan requests and know how the data or information shared with plans can positively impact their patients.
In order for this data to achieve its maximum effectiveness, it must be shared through integrated health information technology systems and effective health information exchange. The goal is to ensure the best technology tools are available to drive data integrity, maximize quality of care and reduce costs.
HIT is essential to ensuring payment under new quality-based model
Healthcare is more dependent than ever upon HIT solutions to keep track of patient information, while also ensuring that information is secure, correct and properly governed. But it’s not enough to just gather and keep the data, it also must be used meaningfully.
Ideally, everyone with a viable need would share records through HIEs, and security levels would be determined by those asking for it and the type of information requested. These systems would allow proprietary picture-archiving communications systems (PACS), laboratory information systems (LIS), EHRs and more from different vendors to talk with each other. Communicating without HIEs is like trying to nurture relationships with no way for the parties to communicate.
Healthcare IT can be used to help facilitate communication among all facets of healthcare, from patient to provider to payer and all points in between. One example is disease management —projected to be one of the industry’s fastest-growing segments. If we are to reduce the number of patients readmitted for the same condition, connecting big data to population health through analytics is a must.
Walking the tightrope
The end goal of better payer, plan and provider relationships is more patient-centric care based on quality, not quantity. Motivated by the need to improve care and comply with government mandates, healthcare reform is happening; it’s up to the payers, providers, vendors and end-users to determine how to best make it work.
With the payoff of improving the quality of care, payers and providers must forge new relationships for the benefit of all — including maximizing audit efforts while also improving data integrity. Full collaboration and communication during health plan audits is an easy step to take while learning the healthcare dance. The rewards are reimbursements and incentives—with improved patient care being the end goal for all involved.
About the Author
With more than 20 years of experience in the healthcare industry, Dawn exhibits a profound knowledge of hospital revenue cycle practices, audit management, and business intelligence analytics. Prior to joining HealthPort, Dawn was the Network Director of Audit and Compliance for a Midwest health system. She has healthcare experience in denials management, organizational development, continuous quality improvement (CQI) and corporate compliance.
The views, opinions and positions expressed within these guest posts are those of the author alone and do not represent those of Becker’s Hospital Review/Becker’s Healthcare. The accuracy, completeness and validity of any statements made within this article are not guaranteed. We accept no liability for any errors, omissions or representations. The copyright of this content belongs to the author and any liability with regards to infringement of intellectual property rights remains with them.
