One challenge faced by all payer organizations is how to best offer prompt, accurate payments to providers that properly reimburse them for the services they provide for members and minimize the frustration and abrasion that providers experience.
I recently spoke with Jyoti Dewan, Zelis’ Director of Client Experience for Claims Editing, and we discussed five strategies payers can leverage to help ease provider abrasion within payment integrity.
Clear explanation of denials
That first denial is a big pain point for providers, especially when there’s not a clear explanation for why a service is not being reimbursed.
The best way to mitigate that is to provide a detailed explanation of the denial. Jyoti offers some insight here:
“It all ties back to communication – from customer service to client policy teams to your team of experts. And then providing detailed response letters that explain the reason for their denial. All that helps with provider abrasion.”
No one likes to have something rejected without understanding why, and providers are no different. Create more transparency in the claims process by showing them your denial is grounded in well-founded edits.
Call on the experts
This is a great time to lean into your team, whether that’s in-house experts or through a trusted vendor partner. They have the expertise to guarantee a quality response.
At Zelis, for example, we have clinicians, nurses, professional coders, and other medical professionals who review claims at high risk for overpayments. They’re able to help with everything from the very first claim to the provider disputes to correcting claims and appeals. They take great effort to ensure the accuracy of each claim, and they’re able to back that up with well-sourced and cited explanations of denials.
Their experience gives them the ability to talk to providers competently and provide clarity on exactly where the problem is.
“If we see that medical records or additional documentation are required, we come back to the client or provider right away to avoid any delays in not having those claims reimbursed on time,” Jyoti adds. “You really need to have that process in place up front to ensure providers receive a timely response.”
In fact, Jyoti’s team has even created tip sheets on how to avoid denials. These informational sheets break down scenarios for billing and coding that show providers how to avoid some of the most frequently seen denials. This is great for building stronger relationships with providers.
Take a consultative approach
At Zelis, we look at our client’s payer payment policies to ensure our edits and claim review concepts don’t conflict with that policy. Providers have this payer policy available to them as well as part of their provider handbook, and we work as a consultant of sorts to support and enforce that policy.
Payers often struggle to enforce a policy, but the right partner can handle that for them.
Jyoti’s team even identifies gaps in policies and works with the payers to write new ones:
“We are here to ensure a remarkable experience for both our clients and their providers, so we like to hear from our clients about what their challenges are,” she says. “We’ll cater our product to their needs or their policies. And, if there are gaps in the policy, we have a team who can help with that too.”
This approach creates a ripple effect to the provider. They have more communication and understanding about what is and isn’t allowed in a payer’s payment policy.
Customize to meet needs
Payment integrity doesn’t work in a one-size-fits-all model. Each payer and provider have different pain points that need to be addressed, and your partner should be able to adapt their solutions to accommodate that.
At Zelis, we strive to be an extension of our client’s payment integrity team. We look at a payer’s approach to edits and claim review concepts, and we adjust our approach to meet those needs. We jump on the phone with providers to help alleviate concerns.
Those small touches go a long way to help reduce provider abrasion.
Don’t underestimate customer service
To ensure a timely and quality response, it is essential to make providers aware of any missing documents or records right away.
Look at how your team is navigating provider phone calls and responding to disputes. Train them to work with providers and help them understand what you need and lean on your vendor partner to strengthen provider relationships.
When you’re already stretched too thin, it’s hard to find time to solve for provider abrasion. A strong team – like the one we have here at Zelis – can do the heavy lifting for you.
It really takes a commitment every day to communicate effectively with providers. If you need help managing your provider relationship, connect with our team today.
