Availity Blog

Leveraging Technology to Enhance Payer-Provider Relationships


2.22.2016 by MARK MARTIN – Director Payer and Vendor Portfolio


As the healthcare industry transitions to value-based models of care and reimbursement, providers and payers need to engage with one another to align and improve outcomes related to quality, cost, and administrative efficiencies.

Creating a successful payer-provider relationship depends on both parties coming to the table with an open mind and a commitment to establishing and maintaining trust. With this foundation in place, they can focus on creating alignment in several key areas.

Data Sharing. Providers and payers each have their own sets of data. Payers have data on claims, financial analytics, and risk models. Physicians have administrative and clinical data that provide rich patient case histories, as well as powerful evidence of better outcomes, lower readmission rates, and higher satisfaction, which can be leveraged in negotiations for higher reimbursement. The key is to forge pathways where these two spheres of data can overlap and be leveraged to benefit both stakeholders.

Automation and Workflow Efficiencies. Siloed data and legacy systems present big challenges. Allowing providers to use health plan data, such as claims and benefit and eligibility information, at the point of care would help physicians move from episodic care to delivering care focused on the continuum.

In addition, tools like self-service portals allows both payers and providers to access complete, actionable data (as opposed to raw data), reducing administrative burdens for both parties, achieving higher performance goals, and identifying coding and care gaps more quickly.

Continued investment in automation is also critical in order to focus precious resources on treating patients and keeping them well and less time on administration and compliance.

Reducing Administrative Burden. Payers can align with providers by offering efficient administrative processes. At the front desk and in the back office, payers can provide tools that enable staff members to submit electronic claims and to quickly check what is authorized at the point of care.

The transition from fee-for-service to fee-for-value is going to take time. Establishing a transparent and collaborative relationship between payers and providers will ease costly and inefficient burdens for both stakeholders and foster the rich, actionable data to ensure that value is achieved throughout the continuum of care.

Visit the Availity booth during the RISE conference in Nashville, March 20-22 to learn how our solutions can enhance collaboration and transparency with your provider network.

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