Health Insurance by Nick Youngson CC BY-SA 3.0

Payer trends, regulatory updates, and policy changes could have a big impact on providers’ operations and bottom line. These are the top five trends you and your organization should know about now to avoid underpayments, denials, and impacts on patient volume.

Payers becoming providers

As payers continue growing their presence in numerous areas, such as primary care and behavioral health, the line between payer and provider is becoming more blurred. Optum, being one of them, has become one of the country’s largest collections of doctors, with more than 5% of physicians in the United States.

Policy updates and regulatory change

Policy updates and regulatory changes are constant, sometimes lacking in guidance or specificity for how to implement or comply. Several significant updates that occurring in 2022 include:

  • No surprises act
  • Repeal of MCIT
  • “Long COVID” qualifies as a disability under ADA
  • Price transparency

Increasing investment, payment integrity technology

By 2025, we can see an increase in payer investment by 30% in fraud detection and payment integrity solutions. The focus for payers is on acquisition and building in-house strategies to reduce cost on inaccurate claims and payments annually.
Core payment integrity solutions payers are leveraging:

  • Claims editing
  • Clinical Validation
  • Inpatient claims review
  • Fraud, waste, abuse
  • Subrogation

Payer conflicts with clinical guidelines

  • National coding guideline conflicts – criteria conflict between states
  • Downgrading ER visits based on final diagnosis – not presenting diagnosis
  • Accessing lab data for downgrades

Payer trends for redirection of care

Recent policies issued at redirecting patient care are aimed to steering patient to treatment outside of hospitals. These attempts have complicated the patient experience and disregarded pre-existing contracts with providers. The policies end up impacting the patient experience in a negative way.

UnitedHealth Group (UHG) recently published an article aimed at plans, members, and their caregivers encouraging “non-complex commercially insured individuals” with employer coverage to seek treatment for common outpatient procedures in Ambulatory Surgery Centers (ASCs) versus a hospital setting.