Listen as Zelis Chief Medical Officer Dr. Timothy Garrett shares key strategies to reduce provider abrasion within payment integrity:  

The friction between providers and health plans has become a significant challenge. To dive into this topic and offer helpful insight, Dr. Timothy Garrett, Chief Medical Officer at Zelis, sat down with Kyle Murphy, Vice President of Editorial at Xtelligent Healthcare. Here are a few strategies they discussed to reduce provider abrasion within payment integrity programs:

The role of communication

Clear communication is essential to reduce misunderstandings and disagreements. Transparency, especially regarding denials, is crucial, Dr. Garrett shared. When payers clearly communicate the reasons behind denials, it can help providers avoid future coding and billing errors, reducing potential conflicts and fostering a more collaborative environment.

Importance of human experts

Dr. Garrett pointed out that while AI plays an important role in payment accuracy, the nuanced understanding of medical coding and the complexities of modern medicine require human experts. Clinicians and coders with deep expertise are essential for explaining the rationale behind payment decisions, ensuring that providers feel their perspectives are understood.

Customization in payment integrity solutions

Payment integrity is not one-size-fits-all. You need customizable solutions to meet the needs of different providers and patient populations. Dr. Garrett noted that “unique providers and unique patient populations require unique solutions.” This approach not only addresses specific challenges but also enhances the effectiveness of payment integrity efforts.

Collaborative approaches with health plans

Health plans should focus on areas where their internal staff can make the most significant impact, particularly in direct communications with providers, Dr. Garrett advises. Outsourcing the more administrative tasks such as claim reviews can free up resources, allowing staff to engage more effectively with providers and directly address their concerns.

Implementing proactive measures

Proactive measures such as having readily accessible and clear payment policies can prevent surprises and reduce the likelihood of provider abrasion. Dr. Garrett explains that a clear explanation of a denial can help a provider avoid similar issues in the future. Additionally, when providers know what to expect in their claims processing, it reduces uncertainty and potential conflict, thereby minimizing provider abrasion.

Emphasizing the importance of collaboration

Fostering a collaborative environment is essential for reducing provider abrasion. By keeping the patient’s interests at heart, both payers and providers can align their efforts to optimize outcomes. This collaborative approach not only improves the relationship between the two parties but also enhances the overall healthcare experience for patients.

Reducing provider abrasion in payment integrity is a multifaceted challenge that requires a lot of collaboration and transparency. Working together is the only way to truly solve for this. With a few changes – like those mentioned here – payer organizations can build more effective and less contentious relationships with healthcare providers, ultimately leading to better patient care and more efficient healthcare systems.

Zelis has a team of experts who specialize in this and are ready to help. You can learn more about our payment integrity solutions here.