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Lack of payer, provider info sharing complicates shift to value-based care

Although collaboration between payers and providers will be critical if they are to succeed in transitioning to value-based payment models, they continue to struggle with information exchange in the current fee-for-service environment.

That’s the finding of a new survey of 40 health plans and more than 400 practice- and facility-based providers, which found significant communication gaps between the stakeholder groups.

Also See: Inaccurate provider data dog payers

In the survey, conducted by health IT vendor Availity, the vast majority of payers and providers (84 percent of practice-based providers, 76 percent of facility-based providers and 68 percent of payers) view administrative waste—finding the right point of contact, long wait times and frequent policy changes—as a significant cause of poor communication.

In fact, the survey results show that slightly less than half of practice-based providers report difficulty communicating with and interacting with payers, compared with almost a third of facility-based providers. Among the top issues identified by providers as leading to dissatisfaction with payers are: redundant information requests, denied claims and uncompensated care, as well as inconsistent rules among health plans.

“The payers and the providers have created administrative waste, and that’s one of the significant causes of poor communication and is adding to the cost of healthcare,” says James Leatherwood, Availity’s product manager for portals. “That comes in a variety of ways, including multiple requests for the same information, which just add cost unnecessarily.”

According to Brian Kagel, director of market research at Availity, providers in the survey communicate with an average of 17 to 20 payers per week, and as a result, the problems associated with administrative waste are amplified.

“Often, representatives from multiple payer units will unknowingly contact a provider seeking the same information, leading to provider abrasion,” notes Kagel. “Until providers and payers can address this challenge, it may be difficult to accurately measure value-based outcomes.”

Currently, when providers have questions about prior authorizations, denials or payments, they call the payers. In the survey, more than 90 percent of providers and 68 percent of health plans indicated that they consider the phone to be their primary means of communication.

“Frankly, I was very surprised that 90 percent of the providers think that the phone is the best way—or, at least, the most commonly used way—to reach out to the plans,” adds Leatherwood, given the long wait times associated with this mode of communication and other inefficiencies.

While online portals are a potential solution for better managing communications, the providers and payers surveyed view the technology differently: 60 percent of payers would prefer the use of online portals as the primary means of communication, but only about 40 percent of providers were as enthusiastic.

“The plans would much prefer the providers to use the electronic tools,” observes Leatherwood. “The providers would prefer to be able to get the answer that they need, regardless of where that comes from. They don’t see the portal as the most effective way to do it based on our research.”

Nonetheless, multi-payer portals are seen by providers as simplifying the workflow by reducing the number of sites that have to be checked for patient eligibility, benefits, claims status and other insurance-related data. In the survey, a multi-plan portal was preferred by 42 percent of facilities-based providers and 35 percent of practice-based providers.

Ultimately, Leatherwood believes that having the ability to share information in advance of treatment—rather than just after care is delivered—is where the industry needs to improve if value-based payment models are to be successful.

“When the plans and providers work together, healthcare gets better,” he concludes, resulting in “better outcomes for patients, creating a healthier America, as well as saving money and reducing the costs of care.”

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