Providers and Payers Can Address Challenges From Common Ground

Over the last decade, healthcare delivery has changed significantly in the U.S., shifting from a fee-for-service model, reimbursement based on the number of services delivered, to a value-based care model, reimbursement based on quality of care and patient health outcomes. This shift has significantly changed both healthcare delivery and reimbursement.

The evolving relationship between providers and payers and its impacts on the healthcare delivery system are core focus areas for CodeToolz.

Before We Get Started

We assure you, there are strategies your practice can employ to tip the scales in your favor, ensuring more equitable and beneficial contract negotiations with payers.

Achieving more favorable contracts requires resources, time, and industry knowledge your team may not have. If this is the case, schedule a free consultation with us and we’ll take care of it for you. Link provided at the end of this Article.

We Bring 30+ Years of Successful Negotiations with Payers

Providers and Payers Can Address Challenges From Common Ground

One strategy for providers and payers is to build anew through their commitment to common goals:

(1) Improving Patient Outcomes

(2) Optimizing Finances

(3) Achieving Quality Care, and The Best Patient-Member Experience

More specifically, both types of organizations want robust data and analytics, more efficient operations, and sound technology that supports future growth and innovation.

Understand The Other's Roles, Goals, Processes, and Pressures

Providers have built a presence in their community and a direct connection with clinicians. They hold clinical data, research work, evidence-based care and pathways, and quality metrics. Working with individual patients, clinical decisions and care are based on the patient's unique characteristics and risks, the best evidence for care innovations that are the most effective. They want to offer options to their patients based on data and evidence when making care recommendations.

Payers want to mitigate risks and costs associated with unplanned care and costs resulting from delayed and suboptimal treatment and unnecessary and inappropriate care. They seek to optimize appropriate system access and take a more population-based approach, holding claims data, risk and severity information, and quality information across providers.

What Challenges Do Healthcare Providers Face In Their Relationships With Payers?

Despite the shared goals of improving patient outcomes while managing costs, the road to collaboration is not always smooth. Provider-payer relations often become strained over issues related to payment and quality of care. Payers are sometimes held responsible for negative patient experiences related to financial challenges caused by provider operational issues; while providers, and the prices they charge, are sometimes blamed for the skyrocketing healthcare costs facing payers.

One key obstacle to establishing a collaborative provider-payer relationship has been physician distrust of payers, the result of decades operating under a system that set the financial interests of payers and providers against one another.?A beneficial provider-payer relationship requires physicians and payers to transition from their prior roles to working as partners.

The lack of trust can only be overcome if the payer actively works to earn providers’ trust. Payers have a wealth of resources they can share with physicians. Timely sharing of patient-level data and information is key to transforming the payer-provider dynamic and creating a collaborative partnership with the goal of advancing patient-member care.

What’s the Solution? Collaboration

Healthier conversations / payer contract #negotiations occur when #physicians and #managedcare organizations come together, with an open mind, and an agreement on the fact that healthcare today is too expensive. The market demands more affordable solutions and products. The best way to deliver that is to work together and not against each other.

Regardless of structure, goals of the relationship can include:

(1) Delivering integrated care and coverage options that combine plan and provider

(2) Partnering to reduce total cost of care on a per member and population basis

(3) Structuring the relationship to reward desired performance and outcomes

Summary

Partnering is challenging. However, tapping into the hard-won strengths of a payer or provider counterpart may be the fastest and most valuable route to achieving care, financial, and market goals.

Before entering contract negotiations, clarify your goals for the negotiation, whether that’s increasing the practice’s net revenue, improving reimbursement accuracy, or putting stricter terms in place for overdue payments.

Once you’ve identified and prioritized your goals, be prepared to present your requirements clearly and concisely. You need to be ready to demonstrate that any demands are reasonable, be prepared to respond to potential arguments with data and evidence to support your requirements.

The Physician's Advocate in Payer Contracting

Our roots in payer contracting run deep, making CodeToolz one of the most effective payer contracting and reimbursement firms in the country.

Gain the advantage of a team that regularly communicates with the nation’s biggest payers, leveraging our experience and partnerships to secure contracts that help you enhance your ROI.

Starting with your top 5 payers, our team partners with you to analyze and communicate directly with payers to obtain better rates and competitive terms, while you focus on patient care.

Contact Us Today (512) 787-1852 or Schedule Your Free Consultation / Demo here .