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An excellent article by Mackenzie Bean for Becker’s Hospital Review identified, “One of the largest sources of tension between payers and providers revolves around clinical decision making. Physicians often grow frustrated or feel undermined when they decide to admit a patient after a face-to-face interaction, only for a payer — removed from the situation — to deny the case, claiming the admission wasn’t medically necessary or appropriate. However, what many physicians may not realize is their own clinical peers are behind those decisions to deny claims.” Easing Provider Tension
“Another pain point for healthcare organizations is trying to reconcile physicians’ recommendations with the stringent protocols outlined by payers.” – Mackenzie Bean for Becker’s Hospital Review
Easing Provider Tension
One concrete effort, by payers, not only financially benefits both parties, but builds trust for the long-term. Addressing the “largest source of tension”, payers choosing a third-party for medical necessity review removes the payer from the role of being the “Big, Bad Denier” of all good patient care.
Instead, the payer moves to the ‘other side’ of the table and works with the providers as partners. The tangible tools a good third-party reviewer shares include on-demand access to reports. The reports drill down through 5 integral metrics the payers can share with providers for transparency and to begin a conversation about process improvements.
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All the transparency and cooperation allows for open conversations with front-line providers about the application of medical necessity criteria and utilization management. Over time, the front-line providers build trust with the payer network with a better understanding of the downstream processes and expectations.
They then see that the MNC is evidence-based and applied by clinicians, like themselves. The interactions or professional peer-to-peer discussions focus on patient care more like a consult than a teacher-student dynamic.
An article in Managed Healthcare Executive, There are four key components at the root of the changing dynamic between payers and providers.
- Cost and charge transparency
- Incentive structures
- Care management
A third-party reviewer addresses 3 of the 4 major criteria for improving relationships. As Providers understand the shared data and processes, they tend “to reciprocate this good faith by no longer making unjustified, blanket demands for rate increases, and instead come to the negotiation table ready with cost and quality data that clearly illustrates a system’s value proposition to the payer and the members it serves.”
Cost and charge transparency
Hospital finance, revenue cycle, and managed care departments can then work collaboratively in performing a thorough chargemaster pricing analysis, and ultimately, assess both price and cost to confidently justify to payers (and consumers), because of the shared data and trust.
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