Payment integrity programs are developed to provide correct claims processing, adherence to contractual rates, and compliance with payment rules. These efforts are essential for maintaining the financial stability of healthcare systems and making certain that patients receive appropriate care. That being said, they can produce friction between payers and providers, originating from disputes over claim denials, decreased reimbursements, and the administrative burden associated with claims adjudication.
Providers are under considerable pressure, with inflation at 3.3% driving up hospital costs. Additionally, cuts to Medicare physician payment rates are making it more and more challenging for physicians to maintain their practices, adding 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, mainly from internal medicine and family practice. Healthcare organizations must find ways to compensate for these shortages, with increased billing on claims being one potential method to recoup costs. Unfortunately, this can increase tensions between payers and providers.
As payment integrity becomes more important 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.
Improving communication around claim denials and payment policies is one primary method to reduce provider abrasion. Readily available policies can reduce the chances of surprises by helping providers know what to expect when processing claims.
The next important 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 some time for technology to fully comprehend 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 unable to explain complex payment integrity decisions like clinicians with extensive coding knowledge and coders with deep clinical knowledge.
Another effective approach is tailoring payment integrity solutions to meet the unique needs of various providers and patient populations. Sometimes, a payer might allow claims from a specific provider offering advanced treatment considered investigational that might not be allowed from another provider. It's important for payer organizations to handle such situations in a custom manner.
One more vital 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 lead to 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.
Click here to read more.
