In the modern healthcare environment, tools and processes that foster better payer-provider collaboration are imperative.
Hospitals and health systems must continuously communicate with the insurers that ultimately pay part or all of their patients’ bills. The health plans have a vested interest in how their covered members are treated and in their overall health outcomes.
Thus, processes like utilization management (UM) and care management exist to create alignment between payers and providers.
However, more effective communication tools and processes must be adopted for utilization management to deliver on its aim to align the standards of payers with the care provided to patients.
Let’s take a closer look at the current state of payer-provider collaboration. Then, we’ll examine how the right technology can change such relationships for the better.
Understanding Payer-Provider Alignment and Collaboration
A large majority of patients have health insurance (more than 90% as of 2020, according to the US Census Bureau). That means providers and payers interact very frequently, and the healthcare industry would benefit from an optimized approach to these interactions. Healthcare Finance News provided one example: some of the most successful hospital-at-home programs stem from strong payer-provider partnerships.
Insurers don’t want to spend more than is needed for patient care. Prior authorization and utilization management are examples of processes where providers and payers work together to manage costs.
Highly manual approaches to utilization management can leave providers feeling like they’re unable to apply their knowledge and experience, relegated to more administrative work than should be required for their roles. Similarly, when alignment on patient status determinations isn’t achieved in the first interaction, extra administrative work and peer-to-peers can add unnecessary time for staff on both sides of the issue. Delays can be frustrating while seeking out information or waiting for a message to be returned.
However, with the right technology solutions at play, care management can be more efficient and rewarding for the utilization management teams conducting the work. Improving payer-provider collaboration through technology can help address these issues while still prioritizing high-quality care.
Transforming Payer-Provider Collaboration With AI and Algorithms
Automating tedious tasks in utilization management and using artificial intelligence (AI) and purpose-built algorithms to help predict patient status can lead to some major benefits.
Providers are freed up to spend more time on the most complex and time-sensitive cases. This increased capacity to work directly with patients can improve health outcomes and lead to higher job satisfaction for clinicians – important during the current staffing shortage which is only predicted to worsen in the coming years.
The right digital solution makes information-sharing and decision-making easier for both providers and payers. By accessing relevant and accurate clinical data in an AI-driven platform with enhanced machine learning capabilities, providers cut through the noise of a standard EMR to see the key information for a specific case, leading to reduced denials and delays. When providers offer shared views into this same, real-time data to payers, everyone is literally on the same page with both efficiency wins and accelerated alignment for each patient’s care status. In fact, a recent study found that a national payer achieved up to 83% more efficiency with case reviews, when deploying an AI-driven platform with automation capabilities. According to Chilmark Research, such a solution indicates the value of AI and machine learning (ML) with “automating core functions in the UM process while also linking payers and providers in a manner that can build trust and reduce friction between the two stakeholders.”
Xsolis is proud to offer CORTEX, now known as Dragonfly, a utilization management solution for hospitals and health systems that supports a more collaborative payer-provider model. Watch this video to learn more about how to bridge the gap between payers and providers with purpose-built technology solutions.