Handshakes instead of finger pointing

Michael Rose

Value based reimbursement is in full swing and there is immense pressure on payers and providers to maintain or improve margins.  Yet, estimates show that 9% of the total waste in US healthcare spend is attributed to administrative complexity. Today’s health connectivity is fragmented and out of date.  Many organizations still use paper, faxing, multiple telephone calls and even snail-mail!  The opportunity exists for payers and providers to work together to remove waste from the health system. For example:

  • Many non-patient collections need follow up. This is often driven by lack of understanding of, or access to, payer processing rules.
  • A sizable percentage of pre-service workflows are not required for payment. In this example, both providers and payers invest FTE hours in solving the problem that can be better solved by IT.

IT is the glue between payers and providers, but how often do we actually see a provider organization, a payer and a Healthcare IT vendor working together to solve provider pain points?  I attended the recent WEDI Con conference in Reston, VA and sat in on a joint session between Washington University School of Medicine, UnitedHealthcare/Optum and GE Healthcare that showcased what can be achieved with true collaboration instead of finger pointing.  The issues to be solved with this collaboration included:

  • A considerable amount of submitted claims required follow-up – often with repeated calls to the payer. Many FTE’s were dedicated solely to this process.  This is often driven by a lack of understanding or of access to payer processing rules.
  • Many of the authorization inquiries do not actually require authorization. Again, a laborious process sucking away critical resources.  Payers and providers invest FTE hours in solving the problems that can be better solved by IT.

The goals for this particular collaboration between the payer, the provider and the vendor are to:

1) Keep provider staff within their workflows for improved administrative process

2) Enhance information within the provider workflow to reduce phone calls and eliminate administrative costs

3) Increase user satisfaction and efficiency

My takeaways from this presentation are that no one can solve these problems in a silo.  As the saying goes “it takes a village” – payers, providers and vendors, working together can make a change.  If we fix it here – we can apply that to other organizations.  The “fix” can be translatable to other payers, other providers, other clearinghouse and practice management vendors and other workflows.

*How the U.S. Can Reduce Waste in Health Care Spending by $1 Trillion.  Harvard Business Review, October, 2015


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