Payers & Providers Collaboration Needed to Modernize the Claims Payment Experience
According to McKinsey & Company, insurers are much closer to their vision of near-optimal claims processing in 2030 than they were just a few years ago. HealthPayer Intelligence reports that this means commercial health payers can expect the benefits of an integrated, digital claims payment process that benefits every stakeholder.
A claims payment solution that benefits providers and payers should give providers a choice on how they would like to get paid. Providers should be able to select which modality they would like to receive payment by, whether it is Virtual Card, ACH/EFT, Push to Card, or eCheck, and if they still want to receive paper checks, the solution needs to have that capability integrated as well.
“The message we’ve heard from providers is that they want more choices even sometimes by payer,” Gilmartin says.
Indeed, commercial payers are relying more on digital solutions to reimburse providers. In fact, the adoption of claims payment using fully electronic methods reached 71% in 2020, the most recent year for which the Council for Affordable Quality Healthcare, Inc (CAQH) had complete data. Surely, COVID-19 pandemic pressures played a part, encouraging payers to innovate and invest in next-generation capabilities such as electronic claims payment and digital claims management processes, but the momentum is encouraging.
Despite this progress with electronic adoption and the promise of further innovation, the article notes that commercial payers still leave millions of dollars on the table because of manual or outdated electronic processes.
Avoiding Friction
One digital claims payment experience obstacle noted in the article is possible friction between payers and their provider partners, often hindering both parties from realizing the full benefits of a genuinely integrated digital experience.
“The tension stems from the idea that providers want to be paid for the services that they performed at the rate they submitted, and payers want to pay what they owe,” Gilmartin explains.
Unfortunately, this friction between payers and providers has created claims payment programs that often only benefit one side of the equation.
Government and commercial payers, for example, have traditionally relied on programs that seek enterprise solutions to manage for the exceptions, when instead they should implement solutions that benefit all parties, while ensuring the exceptions are addressed.
“There is a significant amount of fraud, waste, and abuse in healthcare,” Gilmartin admits. The Office of the Inspector General recently found that the federal government recovered over $5 billion in healthcare fraud settlements during the 2021 fiscal year.
The Key Ingredient: Choices
For real success, a digital payment portal needs to provide the choice and integration that providers truly want and payers genuinely need.
A claims payment solution that benefits providers and payers should give providers a choice on how they would like to get paid. Providers should be able to select which modality they would like to receive payment by, whether it is Virtual Card, ACH/EFT, Push to Card, or eCheck, and if they still want to receive paper checks, the solution needs to have that capability integrated as well.
“The message we’ve heard from providers is that they want more choices even sometimes by payer,” Gilmartin says.
It's clear that payers and providers need to work collaboratively in order to create a payments cycle that works for both parties. The article notes that, in order to create the process, there is a need for "data to be exchanged in near real time with APIs can help solve for the inefficiencies and allow for a streamlined experience and improved collaboration between payers and providers."
To encompass all payments, providers need to leverage technologies like AI and machine learning to electronify the paper-based EOBs that create data to be exchanged between systems within the payments cycle. This enables revenue cycle to close the gap for full healthcare data interoperability and allows providers access to all payment information.