Steve Jax

Three ways payers and providers are improving collaboration during the COVID-19 pandemic

July 20, 2020
By Steve Jax

Since the emergence of value-based care, the need for greater collaboration between healthcare’s traditional adversaries, payers and providers, has received lots of attention but results have sometimes been less tangible. Now, as a result of the COVID-19 pandemic, payer – provider collaboration has accelerated at an unprecedented rate within the health industry ecosystem.

Previously, payers and providers realized the importance of collaboration but acknowledged the industry often fell short. For example, a 2019 survey of payers and providers by SPH Analytics revealed 94% of respondents said they believed collaboration is key to success, but 35% of payers and 24% of providers said the “willingness to collaborate” was the biggest barrier to achieving the goal.

Now, with many staff members working remotely during the pandemic, such willingness is growing. Much of this enhanced collaboration revolves around embracing technology while minimizing the use of manual, paper-based processes to facilitate communication, manage risks and control costs. For example, payers and providers that once relied on faxes and mail to share information on paper, which requires employees to be present at offices, are now looking to electronic processes to expedite data-sharing.

Following are three examples of how payers and providers are using technology to enhance collaboration and boost efficiency during the COVID-19 pandemic.

Electronic attachments: Using traditional paper-based processes, a provider may be asked by a payer to submit additional clinical documentation via mail or fax to clarify a diagnosis code in a claim. This process may come into play, for example, when a payer seeks documentation proving that a child who received a booster shot had received the original vaccination in the first place. In the past, a provider might fax a photocopy or print-out of the patient’s record to accomplish this task.

In contrast, electronic attachments streamlined workflows by enabling providers to simply upload the requested documentation to a shared portal that the payer can access. These electronic encrypted documents also reduce the inherent privacy risks of having hard copy medical information lying around. Electronic attachments also help payers and providers improve accuracy and save time by reducing the administrative burden and costs of maintaining paper-based workflows.

Portal messaging: Call centers play an important role for payers, with agents fielding calls from providers seeking information or clarification on benefits and eligibility, claim status and other administrative tasks. However, with the rapid onset of the pandemic and the associated shelter-in-place orders, many payers struggled in the early days of COVID-19 to remotely deploy agents, leading to longer hold times and delays for providers in need of essential information.

To overcome reduced call center capacities, some payers and providers have turned to portal messaging – a simple but effective concept. Leading portals offer enhancements that far exceed what’s available through email messaging or simple web chats, such as security, HIPAA compliance and logging and recording capabilities.

Automated prior authorization: Prior authorizations represent a significant expense for payers and providers. In part because they involve conversations between two clinicians attempting to parse out the rules around various procedures and referrals. Prior authorizations carry a heavy cost for patients as well, in the form of delays in obtaining needed care and decreased satisfaction. Interestingly, research has shown that most provider calls regarding prior authorizations are not associated with requesting authorization but rather focused on whether authorization for a certain procedure is even required.

This process is crying out for automation, with industry-leading solutions doing just that. Via automated prior authorizations, providers log into a portal and determine whether authorization is needed simply by entering three discrete bits of data; group number of the patient’s health plan, procedure code and date of service. Automated prior authorizations also help free staff to focus on more high-value, patient-facing activities while increasing patient satisfaction and expediting the entire scheduling process.

A bright spot
While parts of the U.S. begin to ease sheltering-in-place restrictions, it’s apparent the pandemic has not yet run its course, with several states reporting post-Memorial Day spikes in COVID-19-related hospitalizations. As the healthcare industry continues to grapple with the pandemic, however, increased payer – provider collaboration (much like greater utilization of telehealth) has emerged as a rare bright spot that points the way to a future of lower costs, higher efficiency, higher patient satisfaction and less hard copy paper work to manage.

About the author: Steve Jax is the alliance manager of strategic payer relationships for Availity, the nation’s largest health information network.