Why Is Accurate Provider Claims Payment Difficult for Healthcare Payers?
Claims processing for payers is a complex process with combination of value based and fee for service models, market expansions, and acquisitions. This process also often requires multiple disparate systems. After layering on the constant changes to provider data and the process to onboard, credential, and contract, it is amazing that a provider ever gets paid in a timely fashion.
Challenges Facing Payers and Providers
Providers often do not have the tools or technology needed to store contract terms, determine eligibility and benefits in real-time, and communicate with payers effectively when there is an issue. This can cause difficulty at the patient appointment, prior to, and during the patient’s episode of care. As a result, a focus on admin processes and overhead can distract from clinical care and patient outcomes.
Mitigating Provider Claims Payment Issues
Payers often focus on payment recovery after incorrect payments have been issued rather than fixing the root of the issue. Many times, incorrect payments are caused by the use of inadequate systems to manage the provider lifecycle. This includes provider onboarding, credentialing, and contracting prior to the activation in the network and claims payment setup. Due to multiple disparate systems, processes, and siloed provider directory data, the ongoing provider data maintenance process is not executed in a timely fashion. By making the decision to improve claims payment integrity, providers can mitigate payment issues in the future.
Benefits of Enterprise Provider Lifecycle Management for Healthcare Payers and Providers
On both sides of the issue, payers and providers can eliminate the use of spreadsheets and other disparate systems. Real-time accurate access to contracts and payment terms is the new strategic advantage for providers and payers alike. Disparate payer systems that do not integrate to the claims system and provider directory can be eliminated by implementing a complete enterprise provider lifecycle management system including provider network management and integration to the claims system.
Payers can also better measure outcomes not only by measuring hard savings goals but also by considering provider experience and operational improvements. These changes lead to improved claims payment integrity by reducing the percentage of claims requiring auditing and reprocessing. Existing payment integrity processes and gaps in technology create adversarial relationships between payers and providers at a time when partnership and collaboration are required to move to value based care and transform healthcare for the ultimate healthcare consumer — the patient member.
Payers contribute to incorrect claims payment by:
- Managing provider contract terms on a spreadsheet
- Executing provider contracts containing unacceptable exceptions to the standard network terms
- Not providing accurate and current access to eligibility and benefit information of the network
- Communicating payment information weeks to months after the transaction and not having systems in place to answer questions through online technology
How Can Healthcare Payers Reduce Provider Burnout?
Payers can increase provider trust and minimize provider abrasion by having the systems in place to address issues proactively. A provider network management system and real-time transparency with an enterprise system assists in managing provider directory changes, contract renewal, and term changes. In fact, implementing a robust enterprise solution will also eliminate burn-out of your own provider network, credentialing, contracting, and provider relations teams by giving them access to the information they need to do their jobs more effectively. There are many reasons to transform provider network management. Let’s get started!
Provider Lifecycle Management with Virsys12
Virsys12 can reduce the administrative burden related to Provider Lifecycle Management including Provider Applications, Onboarding, Provider Network Management, Credentialing, and Contracting with Fee Schedules utilizing our transformational applications, V12 Network and V12 PDE (“Provider Data Engine”). These AppExchange managed package applications are built on Salesforce Health Cloud ensuring that all security, compliance, and disaster coverage and scalability are met and backed by Salesforce. Why not start your journey to improve your ROI and delight your employees and providers with a 360-degree view of your provider organizations, their practitioners, and the network they serve.
If you need the extra help, we also provide Salesforce Manages Support Services to train your staff how to utilize Salesforce. Our strategic consulting services assist your organization in planning for success, not just right now, but for the future of your company.
If you’d like to learn more about V12 Network, V12 PDE, and our services, send us a message! We’d love to hear from you.