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Strategies to Enhance Collaboration

A time-consuming authorization process. Complex claim submission and reimbursement processes. Lack of transparency and communication.

These are just a few examples of how the collaboration between payers and providers can break down and negatively impact a health insurance company’s core business.

Often called provider “abrasion,” this friction or dissatisfaction can have deleterious consequences for payers. For example, while provider or physician abrasion isn’t directly measured by HEDIS (Healthcare Effectiveness and Information Set) or the STAR ratings used by the Centers for Medicare and Medicaid (CMS), the impact on abrasion can indirectly impact scores in different ways. Here are several:

  • Quality of Care: HEDIS scores heavily rely on clinical quality measures. If physicians are frustrated or burdened with administrative tasks due to provider abrasion, they might not be able to devote adequate time or attention to patient care. This could potentially impact the quality of care, and thus affect HEDIS scores.
  • Access to Care: Both HEDIS and STAR ratings include measures related to access to care. If providers are dissatisfied with certain payers, they may choose not to participate in certain networks or limit their patient acceptance, which could affect access to care and, subsequently, the ratings.
  • Patient Satisfaction: STAR ratings include measures of patient satisfaction (captured through the CAHPS survey), which can be influenced by provider abrasion. For instance, if administrative burdens lead to long waiting times, less time for patient interaction, or delayed treatments, patient satisfaction may decrease.
  • Medication Adherence: Certain HEDIS measures and STAR ratings focus on medication adherence for chronic conditions. If prior authorization processes (a common cause of provider abrasion) are cumbersome, it may result in delays in patients receiving their medication, which could impact adherence.
  • Preventive Care and Health Outcomes: Many HEDIS measures focus on preventive care and management of chronic conditions. If provider abrasion leads to lower engagement with insurance programs or frustration around reimbursement, it may indirectly impact the preventive services provided, thereby impacting health outcomes.

Provider Abrasion Mitigation Strategies

Are there strategies payers can deploy that will reduce provider abrasion? What steps can health insurance companies take that will ensure positive collaboration between payers and providers?

Below are five strategies payers can deploy to improve provider abrasion.

  1. Improve Communication: Providers often complain about a lack of clear, concise, and timely communication between themselves and payers. Health insurers should actively work to enhance communication channels, ensuring that providers have quick, easy access to necessary information regarding policies, payment procedures, and any updates or changes. Providing a dedicated contact for hospitals or physicians, along with regularly scheduled calls or meetings, can also help create an open dialogue, fostering trust and better understanding on both sides.
  2. Streamline Administrative Processes: Physicians often express frustration over time-consuming administrative tasks related to insurance billing, claim denials, and authorizations. Payers should seek ways to simplify and streamline these processes. This could involve adopting innovative technology solutions for easier submission of claims, faster processing times, and automatic checks for common errors, thereby reducing the burden on providers.
  3. Collaborate on Care Coordination: Payers can involve providers in care management initiatives and decision-making processes, giving them a voice in how care should be delivered and paid for. This includes shared decision-making models, quality improvement initiatives, or care integration programs. Collaboration can foster mutual understanding, align interests, and promote higher quality and more cost-effective care.
  4. Transparency: Transparency is critical in reducing misunderstandings and conflicts. Payers should aim to make their policies, including the specifics of coverage, reimbursements, and the process for claim disputes, as clear and comprehensible as possible. Providing user-friendly online resources and educational materials can also help fill any gaps that may arise.
  5. Value-based Reimbursement Models: Traditional fee-for-service models can create tension as they often fail to reward providers for quality care. Shifting towards value-based care and payment models that reward efficiency and improved patient outcomes can help align incentives between providers and payers. There are several approaches that could be implemented, including shared savings programs, pay for performance (P4P), bundled payments, and the use of Patient-Centered Medical Homes (PCMH) or Accountable Care Organizations (ACO). With these two models, providers are rewarded for coordinating care around the patient’s needs and for achieving quality benchmarks.

Provider abrasion can’t be solved overnight, but the benefits of a pro-active approach to solving this problem can go a long way toward achieving operational and financial success for payers, including improved STAR ratings.

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