How Payer and Provider Collaboration Leads to Value-Based Success

For too long, relations between healthcare payers and providers have been viewed as a zero-sum game – that for every win or advantage one side experiences, there is an inherent loss for the other side. However, payer and provider collaboration must be prioritized to achieve stability and success in the healthcare industry.

Despite the differences between payers and providers in healthcare, an efficient and results-oriented relationship approach between the two groups ultimately benefits all stakeholders.

Insurance companies can be assured that the services provided are medically necessary and in a patient’s best interest. Hospitals and health systems can follow benchmarks set jointly with payers to streamline operations while providing the best care possible. Patients may even have more confidence when choosing a healthcare provider that is responsible in the way they deal with health plans.

How can payers and providers collaborate effectively and create value-based success? 

Prioritizing Payer and Provider Collaboration: Sharing and Using Data

There’s no argument that data, and the analytics that are generated from it, are valuable resources. However, scarcity isn’t a concern when it comes to digital resources. Everyone can use and benefit from this information as long as it’s available – while at the same time acknowledging that both payers and providers would not want, and would be overwhelmed by, unfettered access to all data that lives within the EMR and elsewhere. 

There’s no reason why healthcare payer analytics can’t be informed and supported by provider data, and vice versa. Shared specialized data views can help achieve this while increasing efficiency and building trust among shareholders. Chilmark Research substantiates this idea in a recent report about the next generation of utilization management solutions: “… a shared platform based on standardized criteria and agreed upon thresholds for care can help overcome the trust divide.” 

Real-time data sharing about patient status can reduce friction while supporting more informed and effective decisions by both payers and providers – there is shared value in getting things right the first time, as opposed to a system that is mired in administrative waste, costing unnecessary time and money. Instead of missed calls and delayed responses, everyone can see important updates and foundational patient information at the same time. 

In the same Chilmark study, the time savings were substantial for a national health plan using XSOLIS’ shared platform with its provider partner – up to 83% faster, when coupled with automation capabilities to reach approval on qualifying cases. 

Using a shared framework for assessing cases for review, one that features easily accessible data, supports collaboration between payers and providers. When both groups can establish shared standards for key processes like inpatient admission, streamlined operations make it easier to focus on positive health outcomes for patients. 

Prioritizing Payer and Provider Collaboration: Finding Common Ground

It’s all too easy for payers and providers to fall into an adversarial relationship. Closing the gap between these organizations sets the stage for less administrative burden and reduced friction.

AI and predictive analytics can play a key role in getting both sides on the same page, supporting a neutral and objecive framework for decision-making. The right solution can highlight the most crucial and relevant information for payers and providers alike. 

That ultimately means fewer battles over patient status and easier access to the key data that indicates why a patient should or shouldn’t be admitted.

Realizing Value-Based Success Through Payer-Provider Collaboration

Prioritizing quality of care becomes a more achievable goal when providers and payers can quickly access the most relevant patient data.

By partnering with XSOLIS, providers can achieve precision utilization management through CORTEX®, prioritizing the most time-sensitive, complex, or otherwise important patients. And payers can access that same data to more quickly align on medical necessity determinations – and engage in collaborative decision-making, supported by analytics which are focused on true clinical merit. 

See the CORTEX platform in action.