Are You Hurting Provider NPS with Your Payment Integrity Efforts?

Jan 26, 2021

Look out for these 4 elements of payment integrity that may negatively impact provider NPS (net promoter scores) with your network providers.

The Net Promoter Score (NPS) – an established metric traditionally managed by insights and marketing departments – can drive growth and member satisfaction at your health plan. But provider NPS isn’t always top of mind when setting aggressive cost containment goals. As a result, two elements essential to health plan operations all too often find themselves at odds:

  1. Health plans put payment integrity processes in place to ensure they are paying claims appropriately.
  2. Health plans rely upon the satisfaction of their network of healthcare providers as key to their services’ value to their members.

What if your health plan’s payment integrity processes could augment the payer-provider relationship rather than damage it? Every interaction with your providers is an opportunity to build that relationship – if you have the proper tools in place to support mutual goals and transparent communication.

4 Elements of Payment Integrity Affect Provider NPS

ClarisHealth VP of Client Development Tara Dufrene explains how well-intentioned payment integrity efforts can result in unwelcome provider abrasion.

There’s still so many processes that are broken in that. For instance, we call this a double dip. We find an overpayment, they engage with the provider, they send that overpayment to the payer. In the meantime, someone from the internal side at the payer has found the overpayment, possibly sent out a letter to recover that from the hospital. So, now they’ve sent two refunds. And now they have a debit on that patient’s account and now the payer owes that money back. So, that’s hours of research on the phone, trying to get a hold of somebody to explain what happened. Many times, the payments that come in may not have the accurate documentation, so the hospital could post that to a miscellaneous bucket, and they don’t even know that they have twice the money. So, it’s research on their side. So, there’s just a lot of back-and-forth and activity that has to take place.

Anywhere cross-functional departments can’t coordinate their efforts or access complete information, these gaps in the payment accuracy process can crop up. And still lead to missed savings opportunities. Is low provider NPS a risk at your organization? Look for these 4 scenarios that health plans commonly experience.

1. False positive rates

A concept either generated internally or by a third-party can create an overpayment false positive, meaning the health plan “thinks” it’s an overpayment when it actually isn’t. False positive rates have the potential to cause great harm to your health plan’s provider NPS score, as it may create damage that is more difficult to correct than to prevent. Without good data, insight into this problem is minimal and extremely siloed.

While many providers may feel it easier to pay for what an insurance company has determined to be an overpayment, there are some legal cases where health plan error has caused overpayments to be mistakenly claimed. These “clawbacks” are sure to leave a negative mark on a provider’s perception of your health plan if they feel the claims to be erroneous.

Pareo’s concept management capabilities give plans all of the needed documentation, descriptions and rules, including sample claims, to prevent false positives before approving a new concept. And the A.I.-powered algorithms operate on a multi-dimensional view of data to prevent false positives when detecting fraud as well. While it sounds simple, the ability to combine all necessary information into a singular interface that health payers can access and make decisions from is a unique benefit.

In addition, Pareo supports exclusion lists so you can more finely control your audit results. By accounting for known anomalies and proactively excluding certain providers, you can ensure your advanced analytics don’t cause undue abrasion.

2. Overlapping medical record requests

The old, manual way of requesting medical records is a big burden on providers and fraught with potential minefields. Notably, payers can reopen cases on “good cause,” instances which often lead to those requests being ignored. Moreover, if a provider is deemed an outlier, they can be a target for medical requests that may seem (to them) redundant. Requests that include little to no insights only magnify this impression.

A recent study of providers highlights the extent that uncoordinated medical records requests impact provider abrasion. More than 92% linked the sheer volume of requests to abrasion while 46% describe the process as at least “very abrasive.”


Pareo workflows minimize duplicate requests, enable quick and secure sending/sharing, and support request detail to allow for information to be exchanged in a HIPAA-compliant manner. The discreet and accurate advantage that Pareo gives to the medical record requests is more straightforward than manual processes. Providing relevant information and making it easy to comply with requests creates a prime avenue to boost provider NPS.

3. Full claim denials

Many times, a health plan will deny an entire claim when only a line item or two are incorrect because their systems are inflexible. The inability for said systems to be dynamic and responsive is a big detractor when it comes to provider NPS.

For one, denials are very costly to providers. The process is hardly straightforward and despite both providers and payers being frustrated by denied claims, it is the provider who is at risk for not getting paid. This alone can create undue stress and added tension, which may boil over at technology inefficiencies. Health plans and payers are entering into a more symbiotic relationship, and more can be done to improve the workflow of claims denials.

“A study by the Medical Group Management Association found the cost to rework a denied claim is approximately $25, and more than 50 percent of denied claims are never reworked.”-AAFP.Org

Pareo gives health plans the capability to deny claims at the claim line level to avoid the costly back-and-forth with providers. It also surfaces supporting documentation to validate these findings without page-by-page review. Part of a broader value involving analytics and ROI, our technology solution streamlines the claims process to reduce costs and improve efficiencies for both auditors and providers. By addressing claims denials at a granular level, a provider can more accurately correct information where needed.

4. Outdated provider outreach

In almost all areas of our lives, modern electronic communication rules the day. Not so with the payer-provider relationship. The current process at most health plans relies on manual activities that lack context. Fax, mail and endless phone trees appear custom designed to result in communication breakdowns. No wonder more than 30% of providers report not communicating with payers at all.

Pareo supports provider education and detailed explanations for transparent communication and real-time feedback. No more vague letters and submitting the same type of denial over and over again. Pareo provides a “log” of communications between providers and payers that can prove vital in clearing up issues.

Pareo’s payer-provider portal easily and securely combines claims, related medical records requests, communications records, underpayment and overpayment reporting, and other necessary information. Two-way communication engenders trust and creates a path for collaboration that will prove vital to broader goals.

Data Visibility Makes the Difference in Provider NPS

Providers understand the importance of claims payment accuracy. But those efforts don’t have to result in ill-informed, ill-timed communications that damage this valuable relationship. To that end, we built Pareo with transparency top of mind. Uniting multiple health plan stakeholders – services vendors, internal staff and providers – on a single technology platform leads to efficiencies and shared insights you can’t achieve otherwise.

Now’s the time for total payment integrity

See the ClarisHealth 360-degree solution for total payment integrity in action.

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