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The COVID-19 pandemic has led payers and providers to embrace electronic encrypted documents and other technology — and that has fostered greater collaboration between them.
As the U.S. healthcare system makes gradual and persistent strides towards value-based care, success within this new payment model depends on greater collaboration between payers and providers. Until recently the pace of this engagement has been slow. However, the COVID-19 pandemic has caused an acceleration in payer and provider collaboration.
A 2019 survey of payers and providers by SPH Analytics provides a snapshot of pre-COVID conditions. The survey reveals that 94% of respondents believe collaboration is key to success, but 35% of payers and 24% of providers note that “a lack of willingness to collaborate” stood as the greatest barrier to accomplishing this goal.
COVID-19 has disrupted operations for payers and providers forcing many employees to work remotely. This has caused a greater need for collaboration. A common example is the adoption of technologies that replace paper-based communication, manage risks and control costs. Payers and providers previously relied on faxes, traditional mail and other hardcopy documentation to share information. Their transition to electronic processes has enhanced data-sharing.
Below are three examples of ways payers and providers have embraced technology to promote greater collaboration and efficiency during the pandemic.
To clarify and/or justify a claim diagnosis code, payers often ask providers to submit additional clinical documentation to resolve any questions. For example, this process may be invoked when a payer seeks supporting documentation that a child who received a booster shot received the original vaccination in the first place. Under traditional hardcopy paper-based processes, this could result in the payer sending an initial request by fax or mail, and then the provider faxing or mailing a photocopy or print-out of the patient’s medical record.
In contrast, electronic attachments streamline workflows, allowing providers to simply upload the needed clinical documentation to a shared and secure portal accessed by the payer. These electronically encrypted documents deliver a significantly higher benefit to payers and providers by eliminating privacy risks associated with hardcopy documentation being delivered to the wrong party. Electronic attachments improve accuracy and save time by reducing the administrative burden and costs of maintaining paper-based workflows.
Many large payers rely on call-center agents to handle provider calls regarding benefits and eligibility, claim status, and other administrative tasks. Call center operations were interrupted as a result of state-issued shelter-in-place orders due to the pandemic. Payers faced challenges remotely deploying their agents causing providers long delays in receiving critical information.
To reduce issues associated with lower call-center capacity, some payers and providers have adopted portal messaging solutions, which are a simple but effective concept to overcome remotely deployed call center agents. Many portals have features beyond simple email or web chat, such as secured HIPAA-compliant systems and logging and recording capabilities.
Manual prior authorizations generate significant expenses for providers. According to a 2019 report from the Council for Affordable Quality Healthcare, each manual transaction cost an average of $11 compared with $2 for a fully electronic one. Many manual prior authorization expenses stem from the telephone conversations between clinicians and call center associates as they analyze complex rules around procedures and referrals. This manual process also results in patients experiencing delays in medical care causing decrease in satisfaction with providers and health plans.
Availity has revealed an important insight about provider calls regarding prior authorization: The majority of callers do not request a prior authorization; rather they seek information about whether a prior authorization is even required in the first place. This is a process ripe for automation which would confer several advantages.
With automated prior authorizations, providers simply log into a portal to determine whether an authorization is needed by entering three straightforward pieces of data; the patient’s health plan identification number, procedure code and date of service. Automating the prior auth process can free up staff time allowing them to focus on higher-value patient-facing activities. Thereby increasing satisfaction and speeding up the scheduling process.
Any hope that the virus will loosen its grip on the U.S. has disappeared with the summer’s recent surges in cases and hospitalizations. Although many Americans may have decided that they’re “done” with COVID-19, the virus is not done with them. Nonetheless, the pandemic has driven greater payer-provider collaboration. A paradigm shift the industry has needed for a long time offering some welcoming good news toward a healthcare future with less paper, less wasted resources, greater efficiency and higher patient satisfaction.
Jack Hunt is the senior vice president of healthcare networks for Availity, the large health information network