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3 strategies to boost savings and improve provider and member experience

How health plans benefit from working with a strong payment integrity partner

5 min read


Payers are grappling with a number of IT costs and burdens that can affect the member experience and create friction between payers and providers. SmartBrief recently spoke with experts at Zelis on how modern technologies can help address these problems while improving relationships with providers and members.  

What are some of the current IT costs and challenges payers are facing?

Payers need to foster relationships with multiple vendors while also maintaining integration points between various vendors and data feeds. They often use manual workflows as a “temporary” bandage to achieve integration, but as time passes and other priorities are addressed first, these manual workflows become the long-term solution. This is hard to keep up and can also create business delays due to slower processes that may be undocumented and difficult for new staff to learn.

IT burdens also create friction between payers and, due to prior authorization hurdles, slower payments, and confusing and seemingly arbitrary denials. This, in turn, can lead to patients facing challenges in accessing care, clinician burnout due to unnecessary administrative tasks, and provider difficulty in financing personnel and supplies.

How can technology help?

Technology can help alleviate these burdens by reducing the number of vendors and, in turn, the burden payers’ IT teams need to manage. Technology can also allow payers to build integrated workflows from the start, then continue to review and optimize to ensure up-to-date and efficient processes.

Thoughtful application of technology paired with a human touch can help ameliorate friction:

  • Payments are becoming increasingly speedy due to improved technology and integrations. The Zelis Advanced Payments Platform offers easy-to-use, multi-channel payments and communications through a robust technology stack and key partnerships, like with Google Wallet, for instance.
  • Technology plays an important role in assuring the accuracy of coding on claims. Having a single payment integrity partner using cutting-edge technology can help eliminate overlapping and contradictory payment accuracy decisions.
  • Payers are increasingly moving away from prior authorization, especially for routine procedures. A trusted payment integrity partner can help payers assure accurate payments while decreasing the provider burden created by prior authorization requirements.

There are also benefits for member experience. Individuals are faced with a confusing array of health care plans and services, but technologies that quickly identify and correct errors related to health care claims take away a great deal of the uncertainty.

What are the top 3 strategies payers should embrace?

Move to a pre-payment approach – but don’t forget about post-payment.

Promptly identifying billing and coding errors and other claims problems before payment prevents much of the expense and administrative burden generated by waiting until after payment. This decrease in cost and burden can be realized by payers and providers.

At the same time, because of prompt-payment requirements and the complexity of billing and coding, post-payment reviews remain an important part of a comprehensive payment integrity strategy. Additionally, it’s important for payers to have an open dialogue with their cost containment partner on the best strategies for each market where their out-of-network claims costs lie.

Automate while maintaining the human touch.

All too often, payer organizations rely on labor-intensive manual review processes to perform crucial payment integrity work. Sometimes, this is at the expense of providing personal amenities – such as provider outreach and member services. A payment integrity partner that uses thoughtful automation and AI can reduce administrative costs while shifting internal personnel to focus on the payer’s most important entities – members and providers.

Consolidate payment integrity partners.

Reducing the number of vendors or finding a single vendor that can provide a multitude of services can help streamline operational efficiencies. Plans can achieve a smoother, quicker process for claims pricing and reimbursement accuracy by working with one strong partner that:

  • Supports network management and contracting
  • Offers full payment integrity reviews
  • Has a comprehensive out-of-network approach that complies with federal legislation
  • Can pay claims seamlessly to providers and members.

Further, having just one partner to hold accountable reduces workload for the payer’s internal teams.

Where are payers facing challenges when trying to make these improvements themselves?

Because of the complexity of health care billing and coding and the constantly changing nature of rules, regulations, guidelines and code definitions, payer organizations find it difficult to keep up, especially amid shrinking workforces.

A payment integrity partner with a comprehensive out-of-network solution is often the best route for payers that seek accurate and streamlined payment integrity processes. A good payment integrity partner extends the payer’s team, allowing its internal professionals to provide more personalized services for providers and members while the partner performs the bulk of day-to-day payment integrity work such as claims editing, bill review, diagnostic-related group validation, out-of-network reviews, etc.

A strong partner will understand each individual market across the country. They can support discussions with providers and members about reimbursements and potential balance bills while taking steps to indemnify members from additional costs.

Working with a partner that is fully integrated into the adjudication platform allows for a seamless data transfer and customized workflows that may be needed to support specialized setups. Additionally, when a payer’s cost management partner and adjudication partner have a partnership of their own, it allows for quicker turnaround times when resolving issues and reduced burden for the payer if workflows need updates.

The health care landscape is constantly shifting, and payers face an increasingly crowded, uncertain marketplace. Maintaining good relationships with providers through honest, thorough claim pricing reviews and a fair out-of-network reimbursement process will allow them to offer the highest-quality care to members with no hidden downstream costs. This will create a smooth, easy member experience that supports healthier, happier members.

Zelis creates purpose-built solutions so you can focus on your mission of providing access to quality care at a reasonable cost. Learn more.