Communication is essential in payer-provider relationship

March 1, 2005

Automation doesn't reduce frustration. Rethinking processes and workflow are key steps.

The productive payer-peovider relationship relies on trust and communication to make the most of the collaboration and to effectively service customers.

The payer-provider relationship is based on information. Poor information can lead to misunderstandings, mistrust and lost opportunities for market-share growth. Relationships can flourish when payers and providers work together to ensure the stability of the flow of information, according to 2004 Montgomery Research Inc., sponsored by Capgemini.

SOLUTIONS VARY Although technological issues contribute to many claims processing problems, technology is not always the culprit.

Rich Maturi, senior vice president, Healthcare Delivery Systems, Premera Blue Cross of Washington, Mountlake Terrace, Wash., notes that mutual understanding is often the key to a better payer-provider relationship.

"By having a better understanding of how mutual processes work and understanding each other's role in each process, we can move forward," Maturi explains. "If we don't work with them to understand how they use various tools, they won't use the tools we build. Strong stewardship and mutual service are important to understand what is needed."

Allen Karp, director of national network, contracting and strategy, Aetna, Middletown, Conn., has a similar viewpoint. "By taking the time to understand what is important to physicians and their office staff, and the differing administrative workflows among healthcare professionals' offices, we can provide the options that will best meet their needs to do business with us," Karp says. "Physicians may differ in the preferred ways to interact with us based on workflows or in-office electronic capabilities. For example, some offices may use Aetna's secure Web site while others may choose to connect with us through electronic transactions or the telephone. Ongoing communication, such as focus groups and visits to physician offices, also helps us anticipate and address changes in their needs or in-office electronic capabilities."

Once both parties each understand the work processes involved, a dialogue can begin about ways to improve claims handling.

"Providers want a single 'look-and-feel' tool for all transaction types. In many cases, we can't do this because of conflicting priorities and other problems, so we have to develop different tools," explains Alan Smit, senior vice president and chief information officer, Premera Blue Cross of Washington, Mountlake Terrace, Wash. "Why would you develop a tool without collaborating with the user?"

The priorities of the customer, healthcare professionals and office staff, need to be kept in mind when determining ways to improve business and information transactions.

"We need to recognize that different providers have different needs," says Karen Ferrell, senior vice president, national contracting and provider network, CIGNA, Bloomfield Conn. "One solution may not fit all providers. One facility may need more administrative information, such as eligibility or benefits, while a specialty provider may need more clinical or referral information."

ELECTRONIC TRANSACTIONS Increased use of electronic transactions benefits payers and healthcare professionals. Electronic transactions also can result in more accurate information and reduced administration for physician practices, and the need for fewer phone calls. Physicians also can get information 24 hours a day, 7 days a week, and fast. For example, Aetna's electronic connectivity benefits physicians through improved turnaround times for referrals and pre-certification; physicians who submit their claims to Aetna online can receive expedited electronic payments, according to Karp.

"Options should help healthcare professionals be more efficient, reduce costs, and be easy to use," Karp says. "The electronic environment is constantly evolving, as is the industry, so it is also important to be open to continually gathering input and refining processes to meet the changing needs of healthcare professionals. Healthcare professionals are more willing to embrace technology and electronic options when they understand the security, simplicity and reduced cost of administration are to their benefit."