The Network Bridge: Building a Collaborative Relationship between the Payer and Provider

Payers and providers undoubtedly need each other. Provider relationships with payers can be very dynamic, and often times they are challenging to navigate. As a result, payers and providers must resolve to collaborate more often, starting with regular open communication.

By Nicole Marin, Network Enrollment Manager, Zelis

The healthcare arena is facing increased scrutiny and cost pressures, forcing providers and payers to re-examine their processes in order to better align with their business goals.  As the Network Enrollment Manager at Zelis Healthcare, I am constantly evaluating how payers and providers can better align around common goals. For payers and providers alike, reducing bureaucracy and inefficiency makes sense.

At first glance, it may seem as though healthcare providers and payers have competing priorities. However, I have and continue to see many similarities between both parties. In previous roles, I have worked for insurance provider relations on the payer side, and served as a hospital contracting officer on the provider side. I have learned that provider relationships with payers can be very dynamic, and often times they are challenging to navigate.  A common concern the healthcare providers have is the ability to address and resolve issues with payers. As a result, payers and providers must resolve to collaborate more often, starting with regular open communication. Once communication is improved, and trust is gained, we can tackle health care transformation with a team approach.

Providers play a unique role on the front line, sometimes laden with uncertainties about the evolving nature of healthcare. But as Zelis develops solid relationships with providers, we can help them understand how their patients, and their claims, are being addressed beyond the point of care. With a focus on recruiting providers, coupled with a firm commitment to our clients and providers, Zelis has come up with new tools and processes to reduce the administrative burden for all parties in an effort to increase efficiency. Reports estimate that physicians spend 15-20% of their time on administrative tasks1. Therefore, one way to help reduce the administrative burden is to work with providers under agreements that can ultimately stem the tide of increasing provider costs for collecting out-of-network payments.

Moreover, a successful relationship with our providers builds upon the understanding that the efficacious management of their revenue cycle, and their insurance claim processing, are key components of their financial performance. As providers feel mounting pressure to keep up with policy changes, often times they may feel forced to spend more time on administrative tasks and less time on clinical care. We can address the changing needs of both the payers and providers using a team approach to finding cost-effective solutions. The payer has substantial value with the ability to reduce the administrative burden on the provider, which in turn can result in fewer appeals and greater member satisfaction.

Member satisfaction extends further than economics. In addition to financial benefits, finding the right providers for the clients’ networks is also an important goal. This starts with provider-payer engagement and excellent customer service. It is imperative that as our clients thrive, they have a diverse network that mirrors their growth. By growing the provider network, it allows us to develop improved relationships with providers, and ultimately act as a resource, while confronting narrow networks on the payer side. Upon joining Zelis, what struck me about the network we are building is the large reach we have and the variety of providers we deal with on a daily basis nationwide. From large medical centers, to office based medical practices, this diverse population of front line clinicians allows us to have our finger on the pulse of healthcare across the country.

Payers and providers undoubtedly need each other. A key area for payers and providers to align is administratively, with a focus on building efficiency and cultivating goodwill. Payers, providers and members cohesively exist on an engagement continuum. As we work together throughout market changes, we know that claim analysis and assessments are the foundation in taking a proactive approach to provider engagement. Building on a customer service centered approach, and a level of trust, we recognize that we have a common purpose; we should treat providers as partners, improve communications for all stakeholders and try to achieve true harmony in the ever-changing healthcare industry.