Reducing provider abrasion is often a top challenge faced by regional health plans. And the consequences are big if not properly addressed.

Often caused by payment disputes, administrative burden, and/or a lack of transparency in the reimbursement process, provider abrasion directly affects the ability to build and support strong provider networks. This leads to reduced access to care, lower member satisfaction, and increased costs as health plans may need to recruit new providers or pay higher rates to keep existing ones.

In other words, it’s vital to take a proactive approach to help ease provider abrasion.

Five strategies health plans can use to ease provider abrasion within payment integrity

1. Transparent denials

One of the most common frustrations providers face in their interactions with payers is the lack of clear explanations for claim denials. When a claim is denied, providers are often left wondering why, leading to confusion and frustration. This lack of clarity can strain the relationship between payers and providers, making it more difficult to resolve disputes and ensure prompt payment for services rendered.

To ease this frustration, take proactive steps to provide detailed and transparent explanations for claim denials. This can include clearly stating the reason for the denial, referencing specific policy provisions or guidelines, and providing any necessary supporting documentation. By providing this information upfront, you can help providers understand why a claim was denied and what steps they can take to address the issue.

Clear communication is essential in any relationship, and the payer-provider relationship is no exception. In fact, it may be in your best interest to go one step further and provide guidance on how providers can avoid similar denials in the future.

2. Expert support

Claim issues can often be complex and challenging to resolve. To tackle these issues effectively, consider leveraging the expertise of in-house professionals or partnering with vendor experts.

Clinicians and nurses bring a wealth of clinical knowledge and experience to the table. When reviewing claims, they can assess the medical necessity of services rendered and ensure that they align with established guidelines and protocols. This helps to ensure that claims are processed accurately and in accordance with best practices, reducing the risk of overpayments and improving overall claim accuracy.

Professional coders can also play a critical role, ensuring that claims are coded correctly and follow relevant coding guidelines. By reviewing claims for accuracy and compliance, professional coders can help identify and rectify coding errors that may lead to claim denials or overpayments. Their expertise can also help providers understand the reasoning behind claim denials and take corrective action to avoid future issues.

And perhaps most importantly, third-party experts can allow you to expedite the resolution of complex claim issues by providing clear and concise explanations behind claim denials or payment discrepancies to providers. This not only helps resolve issues efficiently but also improves the overall provider experience, ensuring they feel supported and informed throughout the entire process.

3. Consultative approach

You can significantly reduce provider abrasion by adopting a consultative approach to align your payment policies with the needs of providers.

But to effectively align payment policies, you must first understand the payment policies of the providers you work with. This includes understanding the types of services providers offer, their billing practices, and any specific requirements they may have for claims submission and reimbursement. That’s where a vendor partner can help.

Once you understand providers’ payment policies, you can find any gaps or discrepancies between your policies and those of your providers. This may involve reviewing claims data, conducting surveys or interviews with providers, and analyzing feedback to name areas where policies may be misaligned or unclear.

Once gaps in policies have been identified, you can work collaboratively with providers to address them. This may involve revising existing policies, creating new policies, or providing additional training and support to help providers understand and comply with payer policies.

4. Customized solutions

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. Your goal should be to find a vendor partner that can adapt their solutions to accommodate that.

By understanding the specific pain points and challenges faced by each provider (e.g., complex reimbursement processes, difficulties with prior authorization, or challenges with claims processing), you can adapt your approaches to meet the needs of individual providers.

When providers see that payers are willing to work with them to address their specific challenges, it can help foster a sense of collaboration and partnership. This, in turn, can lead to a more positive relationship between the two parties, reducing abrasion and improving the overall quality of care delivered to patients. (Talk about a win-win.)

5. Focus on customer service

Effective customer service can play a crucial role in reducing provider abrasion. Providing prompt and clear communication, addressing concerns promptly, and offering support throughout the claims process can help build positive relationships with providers.

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.

The wrap up

Minimizing provider abrasion is essential for health plans to support strong provider networks and ensure quality care for their members.

By implementing the above strategies, regional health plans can improve communication, build trust, and reduce friction in their relationships with providers, enhancing the overall healthcare experience for all stakeholders involved.

But when you’re already stretched too thin, it’s hard to find time to solve for provider abrasion. A dedicated team – like the one we have here at Zelis – can do the heavy lifting for you. Connect with us.