Providers and payers traditionally have had a deficit of trust in their relationship due to a lack of shared goals — or so it seems at first glance.
Payers always seem to be saying “no” or asking for additional information from providers that require additional work from billers, coders, and medical records staff. Providers want to treat patients to the best of their ability and get paid quickly for the services they render, and payer requests can be considered a hindrance to those objectives. Sometimes, providers are held accountable for their patient experience due to payment and financial issues originating on the other side.
Viewed from one side of the provider/payer chasm, it’s easy to understand the perceived relationship as less than optimal. However, revenue integrity on the provider side and payment integrity on the payer side are amazingly close concepts that share many ideals and outcomes. This can potentially be one of the key agendas that can bring both payers and providers together to work towards shared objectives and reduce friction across the ecosystem.
The recent trend of scrutiny around Medicare Advantage products from the federal government is driving payers to work closely with the providers to ensure the smooth functioning of the entire financial supply chain without disrupting the healthcare ecosystem.
“When payment integrity and revenue integrity go hand-in-hand instead of head-to-head, it can end the adversarial relationship between the two sides and bring greater harmony, shared goals and collaboration between these groups,” says Ritesh Ramesh, Chief Executive Officer at MDaudit. “It ensures that providers are paid appropriately and promptly and that payers aren’t overpaying, while mitigating the risk of audits, penalties, and clawbacks on both sides.”
Disputes Put Patients in the Middle
Disputes between payers and providers often leave patients in the middle. Take a patient who questions a bill. If the patient contacts the insurance company, they often are directed to the provider to answer questions about what charges appear on the bill. As far as the relationship to the patient, the payer’s responsibility is to adjudicate the claim according to the contract the patient’s employer has with the health plan. Unless the claim is grossly overcoded, there is little the payer can do.
The patient then contacts the provider. Billing departments are notoriously difficult to connect with and not likely to be helpful. They may be unable to explain the reasoning behind the charges, leading them to either decline questions or defer to coders, which adds time and frustration to the process. Few patients are healthcare professionals who understand the intricacies of billing and coding. The patient just wants to know that the bill they received is accurate and that the amount they are supposed to pay is reasonable.
When payment integrity and revenue integrity are considered in tandem, the accuracy of claims can improve, which both speeds up payments and gives patients confidence in their providers and health plans.
Revenue Integrity and Payment Integrity Share Many Common Attributes Toward a Shared Goal
The back and forth between providers and payers not only frustrates patients but also adds cost to the claims process. Think about the time and resources needed for billers to rework denied claims or auditors to examine claims data to discover the root causes of common mistakes that are spurring denials. Payers also have a responsibility to their stakeholders to ensure the accuracy of claims.
For providers, revenue integrity means:
- Advancing patient care and experience
- Maximizing legitimate reimbursement
- Creating operational efficiencies
- Maintaining compliance
On the other side, payment integrity means:
- Enabling great patient experience and retention
- Achieving payment accuracy
- Creating operational efficiencies
- Maintaining compliance
When you examine the objectives of providers and payers side by side, you can see that their goals are similar.
Getting a claim right the first time – while avoiding under- or overcoding – results in maximum revenue in the shortest period. Improper coding, such as one surgeon performing more procedures than the day allows, can result in an audit that could land a provider or a health system in the headlines in a negative way. What’s more, federal audits can go back several years, clawing back reimbursements that the provider or health system already has spent. Because healthcare profit margins remain razor thin, that’s a risk providers can’t afford to take.
Likewise, payers have a fiduciary responsibility to their client employers to ensure that claims are paid accurately. The federal Employee Retirement Income Security Act of 1974 (ERISA) sets minimum standards for most private industry retirement and health plans to provide protection for individuals participating in these plans.
For example, hospitals are now required to publish prices for certain procedures to promote price transparency. Payers should be checking not only the contracted provider rates for any patient visit, test, procedure, or surgery, but also published chargemaster rates to ensure they’re not paying too much for the care of their members.
“With technology, we can level the playing field and check many of these claims instantaneously, ensuring that payers are paying the correct amount, without necessarily having to rely on auditors to find anomalies,” says Dave Cardell, Chief Strategy Officer, Advanced Medical Strategies. “The earlier these checks are done — on both the provider and payer sides — the more accurate claims are for both parties.
Early Claims Checks Bring Greater Efficiency
Billing and claims processes are always changing in response to new payer contracts, updated guidance, common mistakes found during audits, and many other factors.
Deploying technology to check claims prior to submission can catch errors earlier in the process, which means that claims can be amended before the first submission to increase claims accuracy and speed reimbursement.
Organizations successfully driving outcomes with revenue integrity are:
- Breaking down silos and working across the aisle with other functional teams – including compliance, coding, RCM, and clinical – to drive a unified revenue retention and growth agenda.
- Setting up a formal revenue integrity program and a steering committee of cross-functional leaders to meet and share insights on a regular cadence.
- Leveraging data and insights as a storytelling mechanism to deliver value by removing bias and injecting objectivity into discussions and decision-making.
- Defining success metrics and leveraging powerful technology to boost team productivity, streamline manual processes, and establish accountability for tangible outcomes.
- Keeping an open mind to learn from other organizations and peers about best practices to drive outcomes.
Providers and payers share a common goal around claims — ensuring that they accurately reflect the patient visit. The relationship between revenue integrity and payment integrity does not have to be adversarial. In fact, bringing the two concepts closer together can help align provider and payer goals while benefiting patients.
Dig deeper into revenue integrity and how to achieve it by watching this insightful, recorded webinar, Rethinking Revenue Integrity.
