The relationship between healthcare provider and payor has traditionally been somewhat adversarial. The practitioner wants to provide the best possible patient care, without overburdening a patient with claim balances, as well as be compensated quickly and fairly, whereas healthcare payors want to minimize healthcare costs and claim reimbursements. This can lead to challenges for accounts receivable and strained relationships between provider/health facility manager and payor, with the patient as a pawn in the middle. But each of these entities relies on the others for successful outcomes, so it makes sense for all stakeholders to work together to create a more positive and collaborative relationship.
Challenges for collecting payments
It’s becoming more and more difficult for providers to get paid correctly, much less on time. Continually changing guidelines, financial rules, and payor reimbursement practices must be dealt with. Payors want to minimize reimbursements and reduce medical fees, and they may resort to claim denials and slow processing — or even drag their feet when providing documentation. Revenue is also lost because providers lack the time and expertise to follow up on missing documentation or appeal claim denials. There’s also a lack of lack of accounts receivable tracking technologies. These challenges result in large revenue losses for providers and healthcare facilities.
Tips for creating a more positive relationship between provider and payor
Knowledge is power. It’s important that providers understand the payor contract and are involved in the negotiation process to maximize reimbursements and ensure a smoother revenue cycle. Here are some best practices and tips for facilitating a positive relationship between provider and payor:
- Make sure there is open communication between payor and provider. Give the provider access to enough information for informed decisions without inundating them with information.
- The payor should provide a fee schedule that defines all covered services, as well as a definition of medically necessary services.
- Providers should supply complete, accurate documentation to payors to simplify processing.
- A payor contract should clearly outline a dispute resolution process.
- Providers must be sure to consistently reconcile payments to billed claims.
- All parties should use up-to-date technologies for automation of manual processes, data analytics, and recordkeeping.
The role of patient satisfaction in the provider-payor relationship
Another key to positive relationships between providers and payors is patient satisfaction. Naturally, providing the best possible care and achieving the best possible outcomes should be the number one objective for healthcare providers. And payors have a stake in that goal as well. A better the patient experience typically means fewer problems with claim disputes.
Although healthcare providers are the biggest factor in patient satisfaction, the payor has a role as well. The physician is responsible for providing care for a particular health issue, whereas the payor has likely had a long-term relationship with the person and their health issues. It’s important for the provider and payor to keep the lines of communication open to facilitate the best patient care as well as ensure a positive patient experience.
Providers and payors should provide access to patient portals and payor websites so they can be actively involved in their own healthcare. In addition, providers can enhance patient satisfaction through:
- Getting to know the patient and involving the patient in creating a treatment plan
- Really listening to the patient
- Connecting with the patient’s story to understand the factors that influence the patient’s health
- Validating the patient’s emotions
Keeping these best practices in mind will help maintain a good relationship between healthcare providers and payors. These tips will help maximize claim reimbursements to ensure that providers are compensated fairly for their services. These practices will also help optimize cash-to-revenue cycles and reduce collection costs, which is important for healthcare facilities. But ultimately, following these best practices will result in optimal care for the patient, which should be the primary goal for all involved parties.
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Written by Pat Murphy
TruBridge Senior Vice President