Healthcare IT Today Podcast: 4 Opportunities to Ease the Tension Between Payers & Providers

When it comes to providers and payers, there’s no avoiding the tension that exists between the two. Ultimately, one’s revenue is the other’s costs. There’s also the fact that providers and payers are optimizing for different things. Providers want to ensure patients get the best care. Individual clinicians are incentivized to provide more care at the individual level to serve the patient and avoid malpractice suits; at the institutional level, more procedures mean more revenue, typically. Payers, on the other hand, face their own competitive dynamics as they sell to employers and individuals who want low premiums above all else. 

You might be surprised to learn that despite the inevitably of this tension, there also lies plenty of opportunity in the space between providers and payers. In a recent episode on Healthcare IT Today Interviews, Steve Rowe, Healthcare Industry Lead at 3Pillar, and host John Lynn discuss why this tension exists and what can be done about it. We’ve captured the four biggest opportunities below.

The first opportunity is around Revenue Cycle Management (RCM) and claims. Payers have all sorts of different rules around what they will approve and what they’ll deny to balance the tension between keeping premiums low and paying for medical coverage. These rules are sometimes even group-specific. 

The challenge? Providers don’t know what those rules are, which creates difficulties for the member. It’s not easy to understand at the moment what will be approved and what will be denied. That means patients may end up unhappy when a proposed treatment is denied or not paid in full (and they are balanced billed).

The opportunity here is for payers to expose that logic to health systems—essentially preadjucating payment (instead of doing it after the fact). The business rationale: make it easy for in-network providers to get paid in exchange for more competitive rates. Some companies are already doing this:  “Glen Tullman is doing it with Transcarent; he’s essentially trying to intermediate the payer to create a new network. His whole premise to providers is, ‘Join our network because we will pay you the same day you do service,’” notes Steve. “That’s how he’s building his network with the top healthsystem and doctors.”  

In Steve’s experience building an RCM startup and working with a regional Urgent Care chain, he observed that the expertise and institutional knowledge around claims processing was largely in the heads of the medical billing coders. 

There are two main forms of complexity in RCM he highlights:

1. Submitting the correct eligibility information (e.g. specific formatting of member ID numbers)
2. Matching the right diagnostic codes to the appropriate CPT codes, which can be a large and complex matrix.

The risk here is that this institutional knowledge will be lost when these experienced medical billers retire. The processes are very manual, with reimbursements not keeping up with labor inflation. 3Pillar is leveraging AI and data mining to reverse engineer each payer’s algorithm for approvals and denials. The goal is to systematize this knowledge and flag issues proactively, rather than relying on the institutional knowledge of the billing staff.

The vision is to integrate this RCM intelligence engine with clinical documentation tools. That way providers are alerted in real-time during the care planning process about treatments or codes that are likely to be denied by the payer. This will improve the financial experience for providers and patients alike.

There is a significant opportunity for data transformation as regional payers have data that lives in separate systems that don’t talk to each other. The pipes to connect these systems haven’t been built and the data isn’t defined in the same way. Regional payers are often at a technological disadvantage compared to national payers because they still have on-premise servers and haven’t moved to the cloud. The IT departments for these payers are swamped putting out fires. They simply don’t have the resources to take on the work associated with major technology modernization projects.

And here’s the rub: Self-insured employers want highly customized insurance products and plans that require flexible and configurable technology platforms. National payers have invested in modern tech stacks that can support this level of customization. However, regional payers struggle to match this same capability. 

So, there’s a real need for regional payers to create a unified data platform and operating system that can integrate data from various systems (e.g., claims, population health, PBM, etc.). This would result in a simplified member experience while enabling seamless workflows for call center representatives, who often have to navigate multiple disparate systems. This is an area where working with a partner who specializes in this capability would be beneficial. 

Speaking of member experience, it’s now the number one concern of Vice Presidents of Benefits at self-insured employers thanks to a tight labor market. Top-tier benefits are necessary to attract and retain talent. There’s no doubt that there’s plenty of room to improve. The experience is often fragmented and frustrating as members struggle to get accurate information about coverage, costs, and provider networks. 

There’s an opportunity for payers to make their medical policies and coverage algorithms more transparent and accessible to members at the point of care. Steve explains, “I’m excited about this opportunity because we’ve all been there where it’s like, ‘I just want to know if this particular provider for urgent care who is still open at 10 p.m. is in network. I can’t figure that out on the app. There’s not a search function and the call line doesn’t open until 8 a.m. tomorrow.”

What if patients could get real-time answers to their questions? 3Pillar is making that vision a reality through chatbots powered by AI and knowledge graphs. By using AI to combine data from disparate systems, members can get accurate, up-to-date information at any time, from anywhere.

These chatbots could also help to address the challenge of call center representatives needing to navigate multiple systems to piece together an answer for a member. Steve points out one key consideration: ensuring the chatbots are fed accurate data and avoiding hallucinations. Doing so requires careful design and integration with the underlying data sources. 

While none of these opportunities have “easy buttons” to press, they all provide means for payers to differentiate themselves and better serve patients and providers. You can discover even more areas for payers and providers to win in the full podcast episode.