Here’s how payment integrity affects the net provider score (NPS) with providers in your network.

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.

 

“The Net Promoter Score (NPS) — a 14-year old metric that’s traditionally managed by insights and marketing departments – is driving growth and direction at a healthcare company that occupies sixth spot on the Fortune 500, has an operating income of $13 billion, and boasts 260,000 staff.” –WARC, October 2017

 

These 4 key elements of Payment Integrity affect provider net promoter scores:

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 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 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. 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.

2. Medical Record Request

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 are often attributed to ignoring medical record requests. If a provider is deemed as an outlier, they can be a target for medical requests that may seem (to them) redundant. That’s because insight to the information behind the request is limited.

Pareo® workflows minimize duplicate requests, enable quick and secure sending/sharing, and supports request detail to allow for HIPAA-compliant information to be exchanged. The discreet and accurate advantage that Pareo® gives to the medical record requests is more straightforward than manual systems. With everything at their fingertips and compliance with requests made much easier, resolving the outdated processes of medical record requests is an easy way 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 thing, 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. Part of a broader value involving analytics and ROI, our technology solution streamlines the claims process to reduce costs and improve efficiencies. By addressing claims denials at a granular level, a provider can more accurately correct information where needed.

4. Provider Outreach

No more vague letters and the same type of denial over and over again. Pareo® supports provider education and detailed explanations for transparent communication and real-time feedback. This can help the provider-payer relationship, which often breaks down over poor communication.

Specifically, Pareo® provides a “log” of communications between providers and payers that can prove vital in clearing up issues. Pareo®’s portal easily combines claims, supporting medical records requests, and other necessary information along with communications records securely so that health plans can more effectively manage their provider relationships.

Data Visibility Makes the Difference

In April, United Healthcare shared the news that their NPS score reached an all-time high in 2017. This is due to aligning priorities with customer feedback, says UHC, and in 2018  the health insurer is giving enrollees the ability to make strategic decisions based on data – at customer demand. In fact, UHC has focused on several top priorities this year that center around the ability to clearly see and utilize data – at the consumer and provider stages.

Talk to ClarisHealth about how Pareo® can ensure program integrity at your health plan while improving coordination with providers. 

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