In this article, we will discuss the complex dynamics between payers and providers in the healthcare industry.
The Influence of Payers
Payers have significant influence over providers and their behaviors, including an unwritten hierarchy, leading by example, and repetition. They have strong incentives to enroll members and maximize their profit margins, which has led to tactics such as risk adjustment and initiatives to improve the health of their members.
Strategies for Providers
Health systems are struggling to receive the same reimbursement for services as they provide to Medicare Advantage plans. Providers must get their house in order, hold themselves accountable internally and externally, and look for options beyond individual transactions. Collaboration across finance, clinical operations, and compliance can ensure a consistent approach to patient statusing.
For example, a health system in the Midwest was able to reduce observation rates from 25-40% down to 5-15%, resulting in a positive impact on their organization. Through collaboration across departments, they were able to get additional requested reimbursement of 66 million and an additional payment of 16.5 million per year.
Dealing with Insurers
It is important to have a strategy in place when dealing with insurers and understand the process and where you stand when appealing denials. Market pressures and dynamics impact hospitals, and being familiar with regulations and data can help make informed decisions when approaching payers. Providers must create a payer-focused strategy proactively rather than relying on the OIG to come and save them.
Reestablishing Healthy Tension
Payers and providers need to reestablish a healthy tension between them in order to make the healthcare system sustainable. The No Surprises Act has caused providers to treat Medicare Advantage patients as out-of-network plans, which means patients bear the financial burden if the plan doesn't cover what they should be paying for. Chapter 13 of the Medicare Managed Care Manual can provide guidance for grievances from beneficiaries.
Note: This is an AI generated transcript, not edited by a staff writer and is solely intended for educational purposes. If you have any questions/concerns, reach out to events@beckershealthcare.com
This panel was live on 04/05/2023 at the event listed here.
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