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Payers and Providers: Creating Alignment at Covenant Health

by Heather Bassett, MD, on May 30, 2019 6:00:00 AM

Late last month I moderated a webinar with a panel of two industry leaders, Tonya Harrison representing Atrium Health and Sherri Ernst representing Covenant Health. Previously, I explored Atrium Health’s adoption of UM by Exception for Medicare patients and select commercial payers. Today however, I’d like to share the transformative nature of Covenant Health’s approach to payer relations.

The provider – payer relationship is complicated and difficult to navigate. Daily experiences between payers and providers often seem confusing.  Interactions are seamless and smooth at their best but downright hostile at their worst. Providers accuse payers of denying claims endlessly and without reason. Payers feel that patient claims lack clinical merit or weren’t submitted in the agreed-upon manner.

The Division

In my view, the division between payers and providers often boils down to misalignment on two things: information and interaction.

First, information that is accessible and actionable for both payers and providers differs widely. While some payers have electronic medical record (EMR) access, many don’t. EMRs are often cumbersome and hard to navigate. And even within the EMR, or in the clinicals that are sent from provider to payer, data is subjectively viewed and assessed by individual nurses who may have differing opinions about clinically complex cases. When you can’t agree upon the data, you can’t agree upon the financial outcome.

When provider and payer information is misaligned, the tactical things – phone calls, faxes – become a source of contention and waste clinical time on administrative activity. And when both the information being shared and the way it is being shared are up for debate, subjectivity creeps in and leads to friction down the line.

The Solution

Recognizing there had to be a better way, Sherri Ernst and the Covenant Health team took a novel approach to eliminating the division between their system and their payers. In 2018, Sherri brought an idea to the XSOLIS team: she wanted to be able to use the XSOLIS analytics in her interactions with payers. Sherri challenged the XSOLIS team to create a technology portal that would allow for a real-time utilization management information exchange between Covenant Health and her payers – with analytics guiding medical necessity determinations in real time.

The concept went live in 2018: Covenant Health and a national payer are currently working together in Cortex, XSOLIS’ technology platform – payer staff review and approve cases escalated to them by Covenant Health on a daily basis.

Sherri’s initial goals were simple: facilitate communication through a secure, hospital-driven portal; reduce case touches and duplicative administrative work for both her staff and this payer; and reduce friction by utilizing XSOLIS’ analytics as a shared framework with payers. In Sherri’s words, the effect has been transformational: “The most compelling thing about this venture [with the payer] was the relationship. When I look back to where we were from where we are today, I am very happy to say we’re collaborating.”

With both national and regional payers already on board and more joining as we speak, XSOLIS offers a new path forward. We’re working with you to renew relationships, to remove friction, to put the humanity back in healthcare. Join us.

If you’re interested in learning more, contact us and we’ll offer a product demonstration that’s customized to you and we can connect you with other leaders in the industry who have joined the movement towards smarter healthcare.

Topics:InnovationPreventing DenialsPayerPayer-Provider Alignment

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