28 Jun ADDRESSING PAYMENT INTEGRITY AND REDUCING ABRASION
Payment integrity programs are designed 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 proper care. That being said, they can create friction between payers and providers, originating from disputes over claim rejections, decreased reimbursements, and the administrative burden associated with claims adjudication.
Providers are under considerable pressure, with inflation at 3.3%, increasing hospital costs. Also, cuts to Medicare physician payment rates are making it more and more challenging for physicians to sustain their practices, adding to a rise in hospital-employed physicians, now at 77.6%, a 25.8% increase from a decade ago.
Compounding these difficulties, 7% of physicians have left the labor force, mostly 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 heighten tensions between payers and providers.
As payment integrity becomes more important due to climbing healthcare spending and complex billing processes, it must focus on reducing provider abrasion to improve billing practices and relationships between health plans and providers.
One core strategy to reduce provider abrasion is improving communication around claim denials and payment policies. Readily available policies can prevent surprises by helping providers know what to expect when processing claims.
The next important strategy is communication coupled with the human component. While the role of artificial intelligence (AI) in healthcare is a trending topic at the moment, it will take some time for technology to fully comprehend the complexity of medicine and coding. Codes and rules are continuously changing and being added. Payment integrity requires human expertise and interactions to effectively address provider abrasion. AI is not able to explain complex payment integrity decisions like clinicians with extensive coding knowledge and coders with deep clinical knowledge.
Customizing payment integrity solutions to meet the unique needs of various providers and patient populations is another effective approach. Sometimes, a payer might permit claims from a specific provider offering advanced treatment considered investigational, which might not be permitted from another provider. It is necessary for payer organizations to handle such situations in a custom manner.
One more major component of payment integrity programs is the adoption of modern technology solutions that make use of 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 result in 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 improving payment integrity. As the healthcare industry evolves, these strategies and data solutions will ensure efficient payment integrity efforts, ultimately leading to better patient outcomes.