4 Payer Responses to Primary Care Challenges

4 Payer Responses to Primary Care Challenges

Primary care providers are the foundation of the healthcare system. With the pandemic putting its future at risk, health plans can take 4 steps to address this challenge. 

It’s been said that the coronavirus pandemic hasn’t created any new problems; it’s just escalated existing ones. This maxim seems especially true for primary care providers. Primary care practices have really struggled during the pandemic – at a time when their role has never been more important. Patient volumes are down by more than half, which makes it difficult for them to stay afloat in largely fee-for-service arrangements. But even under ordinary circumstances, independent practices tend to operate at an unsustainable net loss of 20 to 30 percent a year. 

Primary care providers are the keyholders for our healthcare goals: improving the health of populations, enhancing the experience of care for individuals, increasing health equity and reducing the cost of healthcare. How can payers support primary care in a way that helps improve the clinician experience so they can better fulfill their role’s potential? Let’s explore the landscape around primary care, including how it has been impacted by COVID-19, how consolidation and other factors are affecting its future, and steps health plans are taking. 

Role of Primary Care  

Even before the novel coronavirus, Americans in an increasing number of “provider deserts” suffered from lack of reliable access to care. As a result, they experience some of the worst issues in our healthcare system: poor healthcare outcomes and increased healthcare costs due to complex conditions exacerbated by lack of management and overuse of emergency rooms. These vulnerable populations are more likely to experience adverse effects of COVID-19, and the difference comes down to primary care. 

2019 report found that Americans with dedicated primary care received significantly more “high-value” services, such as recommended cancer screenings, diagnostic and preventive testing, diabetes care and counseling. Those with primary care also reported better healthcare access and experience, compared to those without. These results are intuitive, but their significance can’t be overstated. 

A primary care provider is often termed the “quarterback” of the healthcare system. It’s usually the longest-term relationship a patient has and, especially in the current environment where interoperability is lacking, primary care often has the most comprehensive health information available. They know the patient health history and social determinants of health, and they understand how the healthcare system operates. 

Conversely, a person without a primary care provider – due to poor proximity, healthcare coverage, schedule availability, or a combination of these factors – may have access to a specialist or two, but they are likely largely relying on a cobbled together arrangement of emergency care and walk-in urgent care. None of which is designed for whole-person care and can lead to complicating events like dangerous medication interactions. 

Pandemic Impact 

With the patient volumes at primary care practices down significantly, revenues have also been cut in half. Even with CARES funding, small business loans and telehealth payment parity made available, it has been a struggle for this group of providers. Recently, the HHS provided nearly $6 million in funding for COVID-19 training and technical assistance activities to 52 state and regional Primary Care Associations (PCAs), which support non-profit and safety net primary care providers. While this is certainly a welcome lifeline, it covers only a small segment of providers and services and doesn’t address the administrative burden that is particularly onerous for primary care.  

A recent survey indicated in May that many practices are at risk of closing in a matter of weeks. Specifically, 45% report layoffs and furloughs, 28% skipped or deferred salaries and 14% have temporarily closed – numbers that have remained constant. In fact, one tool projects a catastrophic loss of family medicine physicians by the end of June – almost 60,000 fewer, leaving over 1,800 shortage area counties. 

Mixed telehealth success

While many providers have rapidly deployed telehealth and virtual care to continue to serve patients and minimize their financial impact, reimbursement  hasn’t always followed and some patients struggle with accessibility. The survey previously cited further revealed 84% of providers report patients struggle with virtual care, and only 57% say more than half of the care they provide is reimbursable while 18% have been denied reimbursement for virtual and telehealth. 

Patient care delays

While the current phase of reopening holds out hope for improving these issues, there continue to be areas of concern. Particularly, patients have been and continue to delay essential preventive and maintenance care due to financial issues. This situation has been growing along with the proliferation of high-deductible health plans. And, once again, the pandemic has aggravated it into a potential crisis. 

One recent survey indicated a third of consumers plan to reduce their healthcare spending. And, unfortunately, “consumers with complex chronic illness and those in healthy families were more likely than other groups to say they would adjust their spending on healthcare visits or medications.” 


Altogether, these concerns are worsening a perennial challenge for primary care providers: burnout. A survey conducted last year indicated 79% of primary care physicians experience burnout, compared to 68% of physicians overall. A study published this year explains why the current crisis is intensifying the burn: too little time with patients, overwhelming paperwork, emphasis of profit over patient care. 

Researchers expressed concern about the extraordinary burden COVID-19 has placed on these professionals. “These findings tell us that we need to prioritize understanding and addressing clinician burnout at a system level and at a local level. The human cost, as well as significant physician shortages expected in the future, make this a critical public health concern.” 

Threats to the Future of Primary Care 

Demand for primary care providers is increasing more rapidly than supply, and provider availability is seen as one of the top barriers to meeting the healthcare needs of patients in this country. In 2013, 53% of states were already experiencing primary care physician (PCP) shortages. By 2025, experts expect that shortage will include 72% of states. 

The number of doctors going into primary care continues to decrease in favor of better-paying specialties. And consolidation – in the form of doctors employed by health systems or payers, or joining larger practices – continues to increase, which further decreases provider access and drives up healthcare costs. 

Another factor contributing to the primary care shortage is our rapidly aging population. For one, physicians themselves are growing older. Fully one-third of currently practicing physicians will be over retirement age in the next decade. In addition, seniors are a rapidly growing segment of the population, increasing by 50% over the next decade, and tend to require two to three times more healthcare than their younger counterparts. At the same time, there continue to be reports of primary care physicians exiting Medicare, due to lower reimbursement combined with higher administrative burden to participate.  

In fact, there is some evidence of primary care providers dropping out of onerous reimbursement arrangements entirely in favor of more predictable compensation models. So-called “membership medicine” like concierge or direct primary care (where patients pay upfront fees for access to doctors) is a small segment of how these physicians practice but is growing in popularity, especially in affluent areas.  

What providers encompass “primary care”?

When you think of “primary care” you may be only thinking of your family doctor. But primary care includes a broad spectrum of credentials – doctors, nurse practitioners, nurses, pharmacists – and a range of specialties that fulfill the general medical needs of patient populations: 

  • Family medicine 
  • Internal medicine 
  • Pediatrics 
  • General OB/gyn 
  • Gerontology 
  • Behavioral health 
  • Community health 
  • Optometrists 

How Health Plans Can Respond to Primary Care Challenges 

The future of primary care stands to impact all areas of quality and satisfaction in healthcare but, perhaps most relevant and impactful for health plans, are the ways it affects short-term and long-term healthcare costs. According to an expert on the intersections between public health, primary care, and health care policy, “If you think that investing more significantly in primary care and preventive public healthcare is expensive, try not investing. That’s way more expensive. And not just economically, you’re also ignoring the suffering that goes on as well.” 

In addition to the potential increased costs, consolidation is also not preventing a loss of primary care providers. As the new president of the AMA relates, “The recent issues during the pandemic with physicians who are employed by large health systems not being able to get the PPE that they need, being disciplined for wearing PPE in certain situations, being furloughed, being laid off, being disciplined just for doing what they thought was best for their patient, I think, highlights the importance of physician autonomy.” 

In the face of these challenges – impacting payer bottom lines, member satisfaction and health, and provider networks – health plans have a few avenues to pursue in shoring up this cornerstone of the healthcare system. Here are 4 ways that payers can respond to primary care challenges: 

 1. Extend telehealth

Health plans providing leeway on virtual care has been a real boon for providers and their patients. But, along with extending telehealth payment parity, effectively communicating those changes and appropriate education really makes this benefit useful. The leader at a technology provider for clinician practices noted, “Most physicians don’t even know how to code correctly for the phone call or virtual visit to take advantage of the changes Medicare (and other payers) have made during the pandemic to increase phone call reimbursement and pay for telehealth visits at the same rate as in-person visits.”

2. Promote value-based care contracts

We wrote before how those providers who were already engaged in alternative payment models were better prepared to weather the patient volume dips associated with the pandemic. Primary care providers seem especially suited to this model because of their role in preventive care and unique ability to screen for social determinants of health and impact overall patient care outcomes. For health plans positioned with advanced technology to offer real-time communication, two-way data exchange, and telehealth flexibility, their primary care provider networks should be better prepared to withstand perceived risks and more open to these modern arrangements.  

CMS is already piloting the Primary Care First project with similar structure and goals. The program covers a variety of providers – MD, DO, CNS, NP and PA – and will be active in 26 regions across the U.S. With a simple flat fee payment structure plus upside revenue sharing, it aims to reduce primary care practitioners’ administrative burden to allow them to focus on effective care and the doctor-patient relationship. 

 3. Continue prepay payment integrity efforts

When it became clear how seriously the pandemic was affecting providers, health plans fast-tracked their plans to transition more payment integrity efforts prospective. Because post-pay audits increase the provider administrative burden and increase costs for payers as well, this move to prepay is a trend that’s here to stay. Especially when combined with provider education and two-way communication, supported by an engagement platform like Pareo Provider, this activity should increase engagement with valuable network providers.

4. Support and engage providers

With the understanding that without providers, there is no effective healthcare system, health plans have been directly supporting providers financially. While this effort is admirable and well-intentioned, it is a short-term solution. But extending technology and policy to reduce providers’ administrative burden promise to offer long-term relief. 

The work providers have to perform in EHRs is particularly burdensome, with primary care providers particularly hard hit among specialties. With around 20 minutes per patient visit, on average, dedicated to this administrative task, it’s an outsized contributor to burnout and minimizes primary care availability. And this time doesn’t even include pulling medical records for health plans’ payment integrity needs. With real-time communication and seamless data exchange – supported by advanced technology platforms like Pareo – health plans can promote interoperability and reduce cumbersome administrative tasks. 

One health plan has launched a new partnership with this intent. This arrangement consolidates all necessary medical records and administrative processes like prior authorizations into one place. By allowing for a quicker and more structured view of patient information, it should reduce documentation time in favor of patient care.  

Pareo Transforms Engagement in Healthcare 

Even before the global pandemic hit our shores, the healthcare industry had been focusing on innovating in the face of coming disruption. Pareo was created with this initiative in mind, supporting health plans at the top of this chain to transform engagement in healthcare. The integrative technology platform may start with payment integrity, but it extends to real-time communication with providers – including primary care – to reduce their administrative burden and add to the time they spend caring for members. It’s an effort with real implications in reducing healthcare costs and improving outcomes. 


Talk to ClarisHealth about how Pareo® comprehensive payment integrity technology is helping health plans deliver on their most advanced digital strategies. 

Health Plans Return to Payment Integrity

Health Plans Return to Payment Integrity

Now that the crisis-volume of COVID-19 cases has started to ease across the country, delayed elective procedures and in-person provider visits are beginning to resume. While providers return to some semblance of normalcy, health plans are returning to business as usual as well. Our health plan clients are making moves to resume retrospective payment integrity audits they paused in order to relieve the provider administrative burden. What does “back to normal” look like for the healthcare industry, and how can health plans do a health check on the lingering symptoms of the pandemic to ensure their return to cost containment operations goes smoothly?  

The “Great Pause” Brings Clarity for Health Plans  

While providers have borne the brunt of the pandemic, health plans appear to have weathered the first months of COVID-19 relatively unscathed – or have they? Even in the short-term, there have been significant changes for health plans. Changes such as receiving more telehealth claims than ever before, heightened data security challenges, and facing rapid upheaval of processes in an already administratively complex environment. What’s more, they have risen to the occasion to support their network providers and members, who have suffered significant hardships during this time.  

In addition, with the dramatic reduction in healthcare encounters, overall claim volumes have dropped as well, especially for those insurers whose populations reside outside of virus hotspots. Taken alongside pledges to accelerate payments to providers and reduce their administrative burden by minimizing claims recovery efforts to only the most egregious cases, this situation has left payment integrity departments with more breathing room in their day-to-day than usual. And it couldn’t come at a better time. 

During periods of great uncertainty like the industry is experiencing now, the most critical skill is adaptability: being able to focus on surviving in the current moment while also building toward thriving in a future that will look different. Increasingly for health plans, innovations to survive in the short-term and thrive long-term look like technology – including both novel uses for existing tools and new solutions to address new (and old) challenges.  

These were trends before the coronavirus pandemic, and the urgency of the situation has only magnified technology’s importance in supporting members, offering work environment flexibility and reinforcing relationships with providers. As the chief medical officer at one large regional health plan explains, “We need to be more open to change, step out of our comfort zones and embrace the unfamiliar. Barriers that have stymied innovation in healthcare aren’t as insurmountable as we once thought.” 

Increased Healthcare Utilization Results in 3 Claims Trends 

Now that health plans have navigated through the short-term impacts and are putting plans in place to position for long-term success, they are better prepared to adjust to the new normal of healthcare. A recent survey indicated that 80% of payer respondents expect a sharp increase in claims over the next few months. For payment integrity departments, that signals a return to processing claims as before, even as some changes in healthcare utilization are expected to continue for a while. Here are 3 claims trends health plans can look out for in the next phase of reopening. 

1. Resumed elective procedures, ER and outpatient visits

The state bans on elective procedures relaxed at the end of April, and patient activity is responding accordingly, albeit slowly. One survey indicates 70% of patients have rescheduled procedures for the second or third quarter of 2020, which holds true across all regions of the U.S. With that resumption, though, sites of care are changing with patients less willing to visit inpatient hospitals. Hospital outpatient settings, ambulatory surgery centers and a physician’s office were preferred. 

In addition, emergency department use and physician visits best conducted in-person are also rebounding. ER visits, which dropped 42% during April, have recovered 21-32% of volume, depending on patient age. Outpatient volumes recovered over 50%. 

As procedures and face-to-face encounters resume there is a concern that the delay may have caused conditions to worsen, resulting in more complex and costly claims. In one survey, “more than one in ten of those who skipped care reported that their condition declined because of their decision to postpone care.” 

2. Continued telehealth, home health claims

For the rest of patients whose maladies can be managed and addressed remotely, telehealth and other modes of virtual care are still a popular option. Its use increased more than 4,000% over the last year, growing from 0.17% of medical claim lines to 7.52%. Now that consumers – and their providers – have been prompted to try it, they have found telehealth lives up to its promise of convenience, without unduly limiting the effectiveness or person-to-person connection of the visit. It also comes at a lower cost, and a new report estimates at least 20% of care could be offered digitally. 

Home health, too, has found its moment for patients who, for instance, regularly receive infusion treatments, need dialysis or require post-operative care. These trends have accelerated due to advances in at-home technology along with payers temporarily relaxing restrictions. However, whether these prove to be temporary changes or a permanent shift remains to be seen. 

3. Increased behavioral health utilization

The stresses of living during a global pandemic, along with increased social isolation due to stay-at-home orders, have negatively impacted mental health conditions for many Americans. Prescriptions for antidepressants, anti-anxiety and insomnia medications spiked in the first months, many for first-time use. At the same time, while inpatient mental healthcare capacity and utilization has dropped, many patients have taken advantage of virtual mental health visits.  

One technology vendor executive attributes this increase to reduced stigma associated with telehealth, along with greater availability. That is a hopeful sign for wellness initiatives, and because counseling is one of the specialties more readily covered by telehealth even before the pandemic, this trend may continue indefinitely. 

How Health Plans Can Improve Payment Integrity Agility 

With the understanding that healthcare may be in flux until a reliable vaccine and/or treatment for COVID-19 is available, health plans are returning to their claims recovery efforts with sensitivity to how this activity affects providers and members. This transition requires agility, which is a cultural initiative and skill. As a leader at a large state-based health plan says, “We put these skills into action during the COVID-19 pandemic, making decisions rapidly to respond to the needs of our members and providers.” 

Responding to member and provider needs with tech innovations 

Adjusting to the rapid changes in healthcare to be responsive to member and provider needs may start with a culture shift, but technology is the enabler. Providers and members both are still reeling from the coronavirus impact, and health plans are best positioned with real-time data to promote seamless communication and continue the shift to prepay. 

Real-time data provides the insights needed to determine how and when to adjust the response. Health plans can leverage an integrative platform like Pareo to ingest data feeds from multiple sources for a fuller view of the claims environment. It’s a first step towards interoperability, which supports both members and providers. 

Seamless digital communication follows. At some point, health plans will begin to roll back the financial relief they have been extending to members and providers. The waived copays and cost sharing for coronavirus testing and treatment. The relaxation of prior authorization requirements. To ensure members and providers don’t end up holding the bag due to lack of knowledge, seamless two-way digital communication is key. Both internally with payment integrity departments and externally with members and providers.  

Pareo Provider includes a web-based portal designed to engage with providers on claims status, education, medical records exchange, data sharing and other relevant two-way communication to foster this valuable partnership. Request a Sell Sheet

Prepay claims processing has come into its own during the healthcare crisis to reduce abrasion with providers. It’s more sustainable than accelerating payments and CARES funds, which have many strings attached, and reduces the costs associated with reworking claims – for both payers and providers. While post-pay payment integrity audits will never cease entirely (combating healthcare fraud, in particular, is largely a post-pay activity), minimizing the administrative burden of “coming from behind” to adjust payments in favor of more prepay work is a trend that’s here to stay.  

Pareo Prepay supports this shift from pay-and-chase to working claims before payment with a concepts repository accessible across the payment continuum and configurable workflows that easily accommodate tight prepay timelines.  Request a Sell Sheet

The Bigger Picture 

Innovations in payment integrity have long been a goal at health plans. Health plans that we speak with continue to drive home the importance of data at this crucial time, to provide a measure of predictability during a situation that’s far from certain. Yet, connecting data from disparate streams and collapsing it into usable insights – insights which can be drilled down into – is still far from available to many health plans.   

Imagine a platform in which your entire payment integrity operations are fluid, accessible, operational – in real time. Imagine accessing configurable reporting that offers actionable insights, tracks KPIs, and connects previously disparate data streams.  

Advanced technology platforms like Pareo put this goal within reach for more payers – not just those with vast resources at their disposal. Pareo now more than ever has the chance to revolutionize the healthcare industry. Are you ready to learn more? 


Talk to ClarisHealth about how Pareo® comprehensive payment integrity technology is helping health plans deliver on their most advanced digital strategies. 

Healthcare Interoperability Poised to Solve COVID-19’s Big Data Crisis

Healthcare Interoperability Poised to Solve COVID-19’s Big Data Crisis

Coronavirus highlights power of big data and the need for interoperability to improve population health. How can health plans lead the way? 

What’s the single biggest weapon used by government, pharma, academic researchers, healthcare systems, and health insurers alike to combat the novel coronavirus pandemic? It’s data. Massive amounts of data. Unfortunately, we’ve said it before, and it bears repeating: healthcare has a data problem. And, like many things in healthcare, the current crisis has brought this deficiency into focus. 

In this article we’re exploring the many uses of big data for the coronavirus and beyond and how health plans can overcome the obstacles to ingesting and processing data from a myriad of sources to achieve interoperability, positively impact population health and secure their competitive advantage. 

Big Data and the Coronavirus: A Unique Use Case

Already, work involving advanced analytics applied to real-world data is seeing success in combating COVID-19. By analyzing publicly available datasets, scientific literature, social media information and their own data, progress of a sort has been made by different groups: from predicting adverse events in coronavirus patients to rapidly developing potential vaccines. But the propensity for healthcare, academics and industry to stick to their silos – and their information right along with them – has limited their potential for reliable successes. 

Challenges to leveraging healthcare data

Despite generating a ton of healthcare data – most of it now digital – much of that data is still incomplete, irrelevant, inaccessible or a combination of these. And the sheer volume makes it difficult to overcome these deficiencies. By some estimates, we’re generating over 2,300 exabytes per year (one exabyte = one billion gigabytes), which is expected to grow at least 36% year over year through 2025. 

While compute power has evolved to handle the sheer amount of information, this data is locked in silos. In the absence of clinical trial data – the gold standard – real-world clinical information from COVID-19 patients is the most useful in guiding medical decisions. Thanks to a decades-long push to digitize healthcare information, this data exists inside electronic health records. Despite the promise of digitization, EHRs have not made it easy to retrieve this crucial data.  

Built as they were with billing efficiency in mind, most of the useful clinical data is stored as unstructured free text. And without a common architecture, labels are inconsistent, which makes sharing difficult – even in rare cases where data is complete. There are reports of providers unable to deliver detailed clinical data on coronavirus cases, largely because it would have to be printed or tediously copied from EHRs, then sent by fax or email, or manually entered into CDC forms. 

Interoperability and collaboration offer keys to success


The new rules against information blocking have been delayed to free up resources devoted to the pandemic response, but the need for data interoperability has never been greater. When health data is shared, front-line providers are informed in real time on patient movement, health changes and diagnoses, allowing them to respond smartly. 

According to the Office of the National Coordinator for Health IT’s Don Rucker, M.D., the current COVID-19 pandemic is a clear example of why the data sharing regulations are so critical. “Ironically, if we had this rule several years ago, we would be in a far better spot for knowing what’s going on with this pandemic. There are fundamental things about the biology of this virus that we don’t know, such as latency, duration of disease and how immunity is built up. It would be easier if we had richer clinical information streams.” 

One success story demonstrates just how essential data interoperability is to identifying vulnerable populations and performing targeted outreach. The regional data network had already taken the steps to integrate health information from numerous providers in the area, so they were well positioned to respond quickly during the COVID-19 pandemic. But they were still limited to barely more than a third of the county’s population in this initiative, which shows there’s still plenty of work to be done. 

Other successes tell a similar story. Working together, sharing information – even among competitors and others that don’t traditionally collaborate – accelerates the path toward viable coronavirus solutions. Making quality data more readily available should be the goal. As one expert in public health research puts it, “How can we continue to work together and invest in these infrastructures so that we can collect data, share that data, and analyze that data rapidly in pandemic situations? Or even in smaller-scale situations, like a localized outbreak of food poisoning or salmonella?” 

Where is all this data coming from?

In 1950, the doubling time of healthcare data was 50 years; in 1980, 7 years; and in 2010, 3.5 years. Today, that rate is 0.2 years—just 73 days. These increasingly varied sources of digital data all offer value, though few health plans are able to ingest and parse all of them. 

  • EHR 
  • Claims systems 
  • CRM 
  • Rx data 
  • PACs 
  • Lab data 
  • Clinical Trial Management systems 
  • ACOs/HIEs 
  • Genomics and research registries 
  • Wearables 
  • Apps 
  • IoT 
  • Chatbots 
  • Medical devices and sensors 
  • Social media 
  • Machine logs 
  • PHR systems 

How Health Plans Can Push Data Interoperability Forward 

Now that the pandemic has reinforced the need for improved sharing of healthcare information, what comes next? Like the push for EHRs to streamline healthcare billing, it’s likely health plans will again have to lead the charge in the journey to healthcare data interoperability. We outlined before 4 steps health plans can take to comply with the new information blocking rules. In addition to technical compliance, there are 3 things health plans can do to promote interoperability more broadly in the industry. 

1. Adopt modern technology with interoperability in mind 

The assortment of fragmented technology and manual systems currently in use at many health plans will no longer cut it. Every internal operations system – the claims adjudication system, CRM, fraud detection, payment integrity, provider outreach tools, member service chatbots and everything in between – must be able to “talk” to each other. Moreover, two-way interaction between external provider systems like EHRs and members’ apps of choice also will be required. Advanced integrative technology platforms like Pareo leverage modern APIs built on the FHIR standard to support interoperability. 

2. Use A.I. to process data 

Once health plans have ingested data from myriad sources, processing that information into real-time insights is the next logical step. But even with data interoperability standards in place, healthcare information is still likely to be largely inconsistent and unstructured. Applications of A.I. like supervised and unsupervised machine learning, natural language processing and more can help overcome these challenges, turning raw data into visualized business insights. 

3. Share insights 

Once a health plan has done the dirty work of ingesting and analyzing healthcare data, that’s where the real value of promoting interoperability comes in. Sharing insights with relevant stakeholders – providers, members, even other health plans – builds trust and the ability to realize the benefits of big data across the healthcare continuum. 

Benefits of Big Data Interoperability 

While healthcare data interoperability promises many benefits during a pandemic, innovations pursued now promise to pay dividends long into the future. We’ve written about a few of these during our recent series of articles covering long- and short-term effects of COVID-19. 

For one, without data interoperability, the transition to value-based care is a non-starter. Sharing mutually beneficial information with providers is the foundation of fostering these valuable relationships. It’s up to health plans to take the reins on opening the lines of communication with providers, and supporting them with relevant clinical information can help them reduce costs while improving care. 

The coronavirus pandemic has unfortunately affected members as well, particularly their healthcare coverage and finances. As a result, they have been more likely to delay needed care – even for chronic conditions that make them more vulnerable. At the same time, they are signaling they are more open than ever before to receiving communications from their health plan. This convergence provides an ideal opportunity for health plans to leverage big data insights for population health management efforts. Advanced technology like Pareo surfaces lists of those members most likely to need engagement and care to improve healthcare access, outcomes and quality. 

Finally, greater information sharing allows health plans to make more informed decisions faster. Where are the errors, areas of high-risk and opportunities for driving changes? Access to the “big picture” ensures strategic planning that secures a health plan’s competitive advantage. 

Health Plans Find Success with Tech-Forward Strategies 

COVID-19 has thus far proved to be a harsh but effective teacher, not least by emphasizing the need for an interoperability record that helps to provide comprehensive clinical insights with a 360-degree view of members and patients. This initiative is only feasible through advanced technology. Those health plans with digital-first strategies already in place are better set up for success, but payers that lag can still make progress and secure their competitive advantage. 

By adopting scalable comprehensive technology and leveraging modern interoperability standards, health plans can position themselves to excel at payment integrity, coordinated communication and population health efforts alike. As the COVID-19 crisis evolves – and in readiness for when the next healthcare crisis presents itself – payers will be able to lead the way in identifying those at risk based on their clinical predisposition, genetics, social determinants of health, and other factors as well as coordinating member and provider engagement. 


Talk to ClarisHealth about how Pareo® comprehensive payment integrity technology is helping health plans deliver on their most advanced digital strategies. 

From Volume to Value: Alternative Payment Models Win During a Healthcare Crisis

From Volume to Value: Alternative Payment Models Win During a Healthcare Crisis

As patient volumes drop due to the COVID-19 pandemic, fee-for-service payment models hurt providers. Is this finally the time for value-based care? 

COVID-19 is decimating provider finances. Hospitals are losing over $40 billion per month in lost revenue due to canceled non-emergent inpatient and outpatient procedures. Physician practice revenue has been cut in half. These financial impacts are the direct result of the volume-based contracts in place at many providers, leading some to ask if this might finally be the right time for value-based care. In the words of one payer executive, “If there’s a silver lining to the crisis, it’s that we will now explore a value-based model which is going to be good for patients, good for providers and good for the community.” 

Let’s examine how fee-for-service reimbursement became the norm in healthcare, how it compares to value- and risk-based agreements, and how health plans are better positioned than ever before to successfully promote and implement alternative payment models like value-based care. 

A Brief History of Healthcare Payments 

Our last article in this series on the far-reaching impacts of the novel coronavirus pandemic called out that the structure of our healthcare industry has been in place for almost a hundred years. For the first half of the 20th century, fee-for-service payments made sense as there were limited numbers of interventions and medications that could be offered, and those were relatively low-cost.  

Medical advancements raise complexity, cost  

As medical advancements were made, complexity and cost increased. When the Medicare and Medicaid programs were created to help the elderly and low-income population receive care despite higher costs, their method of reimbursing for services provided the foundation for fee-for-service reimbursement. Later, as costs continued to increase, payment reform concentrated on payment caps but kept FFS reimbursement intact, which led to providers increasing the number of reimbursable services and patient throughput to maintain revenue.  

The rise of managed care and value-based care 

In the 1990s, “managed care” initiatives slowed the growth of healthcare spending by reducing utilization. But they also concentrated healthcare decision making outside of the patient-provider relationship, which unnecessarily increased friction and led to their demise. In 2010 the Affordable Care Act mandated a few value-based care programs administered by CMS. Bundled payments that offered higher fees for higher-quality providers were also introduced as a middle ground between FFS and capitation. 

Though there have been gains in value-based care contracts, most provider revenues are still based on patient volume. A recent survey revealed that while 57% of provider respondents were participating in value-based care arrangements, 48% report that over three-quarters of their organization’s revenue is tied to FFS. 

It’s not just finances, it’s personal: Provider burnout exacerbated by COVID-19 

The financial hit that providers are taking is secondary to the fact that many are putting their lives on the line as they stand at the forefront of the novel coronavirus crisis. But health plans are paying attention to an underlying issue many providers face: professional burnout. 42% of physicians surveyed in 2018 reported feeling burned out while 15% admitted experiencing some form of depression. Those most likely to be burned out are the same ones most likely to be working the front line: critical care, internal medicine and emergency medicine.  

It’s possible that a shift to value-based care and telehealth could offer more work-life balance for medical professionals, and health plans are taking note as they look to support their networks of providers during and after this healthcare crisis.  

Why Continue Fee-for-Service 

Especially in the short-term, fee-for-service reimbursement provides a straightforward, familiar model that encourages providers to continue to offer healthcare during a time when its most needed. And, as many states lift restrictions on elective procedures, many providers expect pent-up demand for healthcare to rebound patient volume and revenue right along with it. Close to 40% of people who had elective procedures canceled plan to reschedule. 

ACO experiences 

Accountable Care Organizations make up a big chunk of the providers participating in alternative payment models. But with their large Medicare populations, the coronavirus pandemic created more risk than they had planned on. In a survey, more than half of ACOs, which earn shared savings based on total spending, were considering exiting the program due to uncertainty and expected financial losses. 

Fortunately for ACOs, CMS stepped in with a new rule that aims to protect them from unforeseen financial impacts. These changes remove spending on COVID-19 patients from performance calculations, expand the definition of primary care services to include telehealth, and more. Nevertheless, this scare may deter other providers from participating in value-based care arrangements. 

Risk-averse providers

Historically, providers have been reluctant to take on the additional risk inherent in value-based care contracts. And, who can blame them? It has been difficult to come to consensus on what “value” and “quality” really mean, and lack of data interoperability only exacerbates that issue by keeping essential information on outcomes out of reach for providers. Furthermore, even before the COVID-19 crisis, many providers were already struggling due to burnout, financial issues and hospital closures. 

When providers enter into alternative payment models, it takes significant resources. With increasing Medicaid and uninsured populations, they may not have it to spare. Physician practices are closing and increasing consolidations are expected in the wake of the novel coronavirus pandemic. This translates into reduced capacity for preventive care and less provider incentives to engage in risk-sharing.   

6 Primary Payment Models

While fee-for-service will likely always exist in some form, in response to growing healthcare costs (now almost 20% of GDP), public and private payers have launched innovative provider payment models designed to reward value over volume. Source 

  • Fee-for-service 
  • Bundled payment 
  • Capitation 
  • Pay-for-performance / Shared savings 
  • Blended payment 
  • Salary 

Why Transition to Value-Based Care  

While an immediate switch to at-risk contracts may not be advisable, long-term, value-based care promises to position the U.S. healthcare system to better respond to future healthcare crises. Those providers currently participating in alternative payment models haven’t experienced the same drop in revenues as those whose survival depends on patient volume. And they are more likely to pursue population health improvements that stand to keep their patients healthier during the pandemic. 

Surprise assist from telehealth 

One unexpected boon from the pandemic is the increased adoption of telehealth. Investments in telehealth and other methods of virtual care are key moves by providers that lend themselves nicely to value-based care initiatives of lowering the cost of care and increasing patient engagement. These investments were made because payment parity kicked in. Before, according to one survey, 60% of primary care clinicians reported the majority of their work was not reimbursed or funded, a big portion of which was telehealth.  

Now, telehealth allows them to accommodate surges in capacity, if needed, and focus on caring for vulnerable populations, so important during a pandemic that disproportionately affects these groups. As one physician says about the pandemic recovery and the role of virtual care in population health management, “This is going to be a phased-in thing and the sickest of the patients are the ones that we need to continue to be able to see to provide care for and get reimbursed for in a virtual modality.” 

Change slow but inevitable 

Those providers who continue to cling to FFS may be left behind and unable to participate in many future healthcare initiatives. CMS, in particular, has been transitioning to value-based care at an accelerated rate since the ACA was passed 10 years ago. A 2019 report showed that 35.8% of total U.S. healthcare payments in 2018 were tied to alternative payment models, a year-over-year increase of 34%. 

Moreover, the industry has begun to come together on value measurements and alternative payment model frameworks. Government payers and commercial health plans are still the primary drivers of value-based care, but universal standards go a long way towards removing uncertainty by increasing transparency. 

How Health Plans Can Support Alternative Payment Models 

We’ve written before about how payers can best support the transition to value-based care: improve provider relationships and data transparency with the help of advanced technology. That advice hasn’t changed, though the COVID-19 crisis may have increased the importance of these initiatives. 

Provider communication 

Collaboration and shared understanding enabled by real-time, two-way communication with providers is essential to the success of value-based care programs, and there is still plenty of work to do in this arena. A recent survey showed that as many as 18% of providers have zero trust in the payers they work with, and more than a third have no communication with those payers. We wrote in a previous article that the COVID-19 crisis has led payers to increase their support of providers, which may provide an opening for health plans to shore up these relationships.   

Without trust, it’s difficult to ask providers to assume more risk. In fact, a survey found that primary care physicians who trust the health plans they work with are more than twice as willing to engage in risk-sharing. As a stakeholder at a regional commercial health plan puts it, “Value-based care is payer driven, but provider and hospital partners need to come together and recognize something bigger. We’re not just trying to do something niche. We’re trying to help people prosper across our population.” 

Data transparency 

Value-based care initiatives depend on data as well. Data that reveals which populations need targeted outreach and how healthcare impacts outcomes is valuable to payers and providers alike. Lack of data interoperability between payers and providers is the number one roadblock that prevents healthcare innovation.  

Breaking down data silos can help mitigate the differing interpretations of value and quality that hold back progress on alternative payment models. So, measure everything. Every impact—clinical quality, consumer experience, return on investment, and more—should be quantified, analyzed, improved, reanalyzed and continually improved in collaboration with providers. Work with providers to implement an analytics and communications platform to share data insights and work together on continuous improvements and innovations.  

Advanced technology essential 

Value-based care promises to lower the cost of healthcare and improve outcomes. These goals were important before the emergence of the novel coronavirus and are now essential directives. But these risk-sharing contracts require advanced technology in order to implement them. CMS has suspended data collection and quality reporting so providers can focus on patient care, but health plans executing on advanced digital strategies won’t miss a beat.  

With integrative technology like Pareo in place, health plans can seamlessly communicate with providers and ingest electronic clinical care and claims information without unduly burdening these valuable relationships. They can come together in identifying and engaging those members who are in most need and find efficiencies without sacrificing quality or the doctor-patient bond. It’s the future of healthcare and it’s achievable now. 


Talk to ClarisHealth about how Pareo® comprehensive payment integrity technology is helping health plans deliver on their most advanced digital strategies. 

Coronavirus New Normal: What does it mean for health plan members?

Coronavirus New Normal: What does it mean for health plan members?

25 million Americans projected to lose employer-sponsored healthcare coverage due to the COVID-19 recession. How will this disruption affect the relationship between health plans and consumers? 

As of the end of April 2020, about 30 million people in the U.S. are newly unemployed due to the pandemic-fueled economic shutdown, a sharp uptick from the recent historically low unemployment rate. Because, on average, about half of the people in this country receive health insurance through an employer, this situation is threatening healthcare coverage during a healthcare crisis. How is this disruption affecting health plan operations and consumers, and will it create longer-term changes in how the majority of Americans receive health insurance? 

The Financial Impact 

A variety of government and social policies in the 1940s and 50s led to the current state of healthcare coverage in the U.S. where most individuals receive insurance through an employer-sponsored health plan. While that structure functions fairly well during periods of low unemployment and underemployment, it can leave a gap during a climate of economic and job uncertainty. 

In the 6-week period between mid-March and the end of April, the unemployment rate soared from sub-5% to over 16% as efforts to stem the spread of the novel coronavirus ravaged the economy and led to widespread furloughs and layoffs of workers. By some estimates, that massive job loss has resulted in 12.7 million Americans losing their healthcare coverage at the same time they can least afford to replace that coverage. 

Health plans started to see the fallout of this rapidly changing situation almost immediately. One of the largest health plans in the nation reported that the number of its premium base requesting grace periods and payment plans increased from 0.4% to over 3% by mid-April. However, this standard practice of 60- or 90-day grace periods is expected to be not nearly enough relief for many members, leading one to offer premium credits and other financial assistance. 

Recognizing the potential impact to cash-strapped consumers, assorted medical and insurance groups are lobbying for assorted financial and healthcare coverage support measures: 

  • Offer employer subsidies 
  • Subsidize or cover COBRA benefits cost 
  • Open special enrollment periods 
  • Increase subsidies for ACA marketplace plans 

Already enacted is a 6.2% increase in federal matching Medicaid funds to help states handle the pandemic for the duration of the national public health emergency. Included in the eligibility requirements for the enhanced funds are provisions that require states to not unduly prevent qualifying individuals from receiving Medicaid coverage. 

The Healthcare Impact 

Consumers losing their income and reliable health insurance coverage during a healthcare crisis is an untenable situation. recent survey revealed a potentially precarious financial situation for a segment of the population. When asked if they would seek medical attention if they presented with the signature symptoms of COVID-19, 14% said they would avoid care due to cost. Even when asked specifically to imagine a suspected coronavirus infection, 9% still would avoid treatment. These responses were especially likely for those with lower incomes, a group that has been disproportionately affected by the current economic crisis. 

This hesitation to seek care couldn’t come at a worse time as the delays promise to derail chronic condition outcomes as well as public health initiatives related to the pandemic. However, putting off care due to financial constraints isn’t an entirely new experience. An annual poll, most recently conducted in November 2019, showed that a record 33% of Americans put off needed medical care due to costs, a rate that has increased 50% over the past 20 years. 

Health plans and the government have stepped in to encourage people to continue to seek healthcare if they need it. Health plans by temporarily waiving cost sharing for coronavirus testing and treatment, as well as other services for vulnerable Medicare members, and the government by compensating providers for uninsured care at Medicare rates so providers don’t unnecessarily burden patients without a safety net. 

Health Insurance by the Numbers

The latest healthcare coverage data available is from 2018. After years of improvement in the uninsured rate, starting in 2010 with the enactment of the ACA, the rate has increased for 2 years in a row, particularly in states that haven’t expanded Medicaid. 

  • Employer Insurance 55.1% 
  • Medicaid 17.9% 
  • Medicare 17.8% 
  • Individual Market 7.5%  
  • ACA Marketplace 3.3% 
  • Military 3.6% 
  • Uninsured 8.5% 

The Future of Healthcare Coverage 

With the rising costs of healthcare coverage shouldered by employers, and the opening of the ACA marketplace, some analysts predicted that 90% of employers would have abandoned sponsored health benefits packages by now, in the same way pensions gave way to 401(k) plans. That projected reality hasn’t yet come to fruition, though the rates of “underinsured” individuals with employer plans are increasing  

The number of uninsured employed people is also increasing, according to a recent studyIn fact, 70% of the uninsured were employed but not offered an employer-sponsored health plan while 30% didn’t enroll in employer coverage because of high costs. At the same time, high rates of unemployment bring into focus the potential gaps created by tying healthcare to jobs, and we likely have not reached peak unemployment in the COVID-19 recession. 

Single Payer Unlikely for Now 

Though the past couple of years saw single-payer policies gaining traction, strong lobbying against the structure has prevailed for now. However, much depends on how quickly the economy rebounds and to what degree. Large corporations make up much of the enrollment in employer-sponsored health plans and continue to drive that segment, and many of them have weathered this economic downturn with greater resilience thus far 

Though healthcare independent of the workplace is currently more important than ever before, the current system is still working for many people. Enhancing ACA plans and subsidies and expanding Medicaid to more people are the most cost-effective – and quickest to implement – efforts and stand to benefit those most affected by income hardships. 

Higher Medicaid Enrollment 

Experts released a new report that projects unemployment will reach 20% by June 2020, which would lead to between 25 million and 43 million individuals dropping out of employer health plans. Of those, 12 million to 21 million will enroll in Medicaid, 6 million to 10 million will receive individual coverage through the ACA marketplace, and 7 million to 12 million will become uninsured. According to a senior policy advisor, “Our safety net is about to be tested, and it’s going to work a lot better in states that expanded Medicaid.” 

Data Insights Key to Health Plan Response 

Short-term, for health plans this shift means a dramatic change in their lines of businessHealth plans that cannot quickly pivot based on data and market changes are at risk. If employer-sponsored coverage changes for the long-term, are health plans positioned to navigate these twists and turns 

Some payers are already making moves specifically focused on expanding their Medicaid and Medicare portfolios. As stated in the announcement of one of these deals, the health plan’s “strengths and capabilities will be critical to successfully serving new populations if a recession increases Medicaid membership.” At the same time, health plans report uncertainty in their 2020 projections, as small group enrollment drops and Medicaid rolls increase. Health plans are having to prepare for all eventualities, and advanced integrative technology – along with the data insights it provides – can provide the edge they need. 

Evaluate Consumer Behavior Changes 

Health plans are keen to harvest business insights from member behavior during this time. They anticipate the pandemic changing the way care is delivered for at least 1-2 years and likely, forever. Most health plans are anxiously awaiting the emergence from the “first wave” of COVID-19 cases (possibly this Summer) to see how user behavior is affected and try to strategize on long-term effects. 

With so many workers furloughed or laid off, we may see a return to insurance after this first emergence, which provides a strong opportunity for health plans to find an early indicator of longerterm behavior change that would impact their bottom line. Data on utilization of care, self-insured rates, changes in plan levels and HSAs, and more will prove valuable. 

Reduce Administrative Complexity 

Administering Medicaid MCO plans is a more complex operation, especially as CMS has issued waivers to help states be more nimble in responding to coronavirus. Medicaid lines of business also tend to be less profitable than employer-sponsored insurance. Increasingly, health plans and payers are turning to advanced payment integrity technology like Pareo to streamline coordination of benefits and otherwise ensure proper payments to providers.  

And, by virtue of being an integrative platform, it helps reduce administrative lift in tangential operations related to traditional payment integrity efforts as wellPareo supports health plans in seamlessly shifting internal resources to more easily accommodate changes in LOB, and automating communication with suppliers and providers to ensure changes are relayed effectively and efficiently.  

Improve Engagement 

Leaders of health plans know that the way insurance is delivered may change for many consumers and, particularly for Medicaid enrollees, engagement is paramount. Technology enables them to proactively address at-risk populations, like those with chronic conditions who may be particularly vulnerable to disruptions in care. By delivering broader data insights and supporting communication with internal and external stakeholders, Pareo aligns with a broader strategic effort at health plans to “improve engagement in healthcare.”  


Talk to ClarisHealth about how Pareo® comprehensive payment integrity technology is helping health plans deliver on their most advanced digital strategies. 

Coronavirus Crushes Providers. Health Plans to the Rescue!

Coronavirus Crushes Providers. Health Plans to the Rescue!

To support healthcare providers financially impacted by COVID-19, health plans rush to provide funds, ease administrative burden with prepay and engagement initiatives. 

Right now, the healthcare industry is in the thick of the novel coronavirus pandemic, with providers bearing the brunt of the impact. Already risking their health in service of sick and scared patients, providers of all stripes – hospitals and private practice alike – are facing another dilemma. How will they survive financially? With the understanding that healthcare providers are one of our best assets in fighting COVID-19 and ensuring a healthy population, the government and private payers are taking short-term and long-term action to shore up this valuable resource. Immediately, by directly and indirectly paying out funds to providers. Longer-term, by investing in prepay and engagement tools to decrease providers’ administrative burden. 

In recent weeks, there’s not a health plan we’ve spoken with that isn’t striving to support those on the front line as best they can. But we know that health plans will also need support. We have had numerous internal discussions around how we view the current industry situation. Here are some of the short-term and long-term actions we see occurring 

Short-Term Action: Inject Monetary Support 

The COVID-19 crisis has created a perfect storm of financial issues for providers:  

  • In order to keep exposure to a minimum, elective procedures have been delayed indefinitely, and patients are self-selecting to avoid preventive care and other non-emergent healthcare. In our largely fee-for-service (FFS) environment, that means a huge chunk of revenue has evaporated for hospitals and physician practices 
  • In some locations, patient volume is not an issue because of the sheer number of patients needing COVID-19 treatment. However, the number of uninsured and patients with high-deductible health plans means the considerable treatment costs – $20,000-70,000 according to some estimates – will be difficult to recoup. 
  • At the same time, providers are having to devote what little funds they do have to high-priced personal protective equipment (PPE) and ventilators, as well as infrastructure to support telehealth visits. 
Direct payments 

From the government, CMS has released the first $30 billion of the $100 billion earmarked for providers in the Coronavirus Aid, Relief and Economic Security (CARES) Act. This federal stimulus money is based on Medicare FFS volumes and does not have to be repaid. In addition, CMS is offered $34 billion in accelerated payments to providers, again based on Medicare FFS revenueas a loan to be repaid within seven months to one yearAdditional stimulus funds, particularly to providers who serve primarily Medicaid populations as well as those in COVID-19 hotspots, are likely forthcoming. 

Commercial health plans also have stepped up with direct cash grants to providers, in one instance providing up to $200 million through financing guarantees, advance payments and the restructuring of contracts. 

Indirect relief 

In addition to directly paying providers, new policies directed toward members promise to relieve providers of the costs incurred to treat COVID-19 patients. Many health plans have pledged to waive cost sharing for testing and inpatient admissions and reimburse telehealth at the same rate as in-person visits. The First Coronavirus Response Act (the FFCRA) and the CARES Act require commercial health insurers to provide testing and care visits at no cost to further increase the chances of providers being reimbursed for expenses incurred. 

Additionally, health plans are relieving providers’ administrative burden short-term by reducing prior authorization requirements, including for those patients not affected by the virus, and providing triage tools so they can make best use of limited resources. Health plans are also re-thinking payment integrity activities most likely to cause provider abrasion and pausing aggressive post-pay claims audits. 

Long-Term Action: Reduce Administrative Burden 

No matter the short-term relief provided, if the “business as usual” response kicks in, providers – many of whom are either at the front lines or have lost revenue – are likely to grow increasingly frustrated with the red tape that characterizes their payer relationships. The goodwill generated by financial support will dwindle as time goes on. But these challenges aren’t unanswerable. Health plans can rapidly innovate, prioritizing technologies that reduce administrative waste and increase collaboration and engagement between payers and providers. 

Strategic shift to prepay 

With as few as 15 days to make a pay/deny decision on a claim, many health plans choose “pay and chase.” But is this a risk that payers want to take during the COVID-19 crisis compounded by a stressed economy? For some health plans, the pandemic serves as a catalyst to grow prepay effortsAlready a long-term goal for many, the commitment to reducing provider abrasion has prioritized this shift 

This risk of delayed income could be reduced if health plans had a robust prepay operation that could quickly identify and respond to overpayment trends before claim payment. Prepay efforts – while not frictionless – create less abrasion among the provider community and can be continued in extraordinary times like the one we find ourselves in now. In addition, a shift to prepay reduces administrative burdens for health plans and providers while reducing improper payment risk.

What codes should providers use for COVID-19 testing and diagnosis? 

New codes have been published to designate healthcare encounters
related to the novel coronavirus:

  • ICD-10 
    • Pneumonia: J12.89 and B97.29 
    • Bronchitis: J20.8 and B97.29, or J40 and B97.29 
    • Respiratory infection: J22 and B97.29, or J98.8 and B97.29 
    • ARDS: J80 and B97.29  
    • Exposure: ruled out Z03.818, confirmed Z20.828 
  • HCPCS 
    • CDC laboratory test: U0001 
    • Non-CDC laboratory test: U0002 
  • CPT 
    • Test: 87635 

For current Pareo clients, it’s easy to move more claims work prepay. The integrative platform allows a health plan to ingest data from multiple sources (such as CMS, states, claims, etc.), apply successful post-pay concepts prepay, configure workflows to effectively stack internal and vendor efforts – including fraud, waste and abuse mitigation – and make fast payment decisions. 

Engage providers 

Some suggest that health plans cannot move swiftly enough on urgent care coordination responses, like prior authorizations, that have left patients without COVID-19 taking up valuable hospital beds as they await discharge. And, strategically shifting the payment integrity mix to include more prepay internal efforts won’t do much on their own to support valuable network providers and decrease abrasion. Solution? Real-time engagement and communication. 

Some health plans already use tools like portals to push messages to providers, like sending prepay information to providers along with education on how to correct incorrect billing issues. While that is a starttrue engagement is a more encompassing initiative, one that mutually beneficial advanced technology can help support. Think of dashboards that highlight key performance indicators of the payer-provider relationship, integration with the EHR to streamline clinical documentation requests, and the ability to automate underpayment and denials inventory management.  

Proactively and continuously opening the lines of communication with providers eases their administrative burden at a time they need it most. This initiative will pay dividends for health plans and providers alike, long after the threat of the pandemic has passed, paving the way for needed innovations that will transform the industry and set us up to weather future challenges. 


Talk to ClarisHealth about how Pareo® comprehensive payment integrity technology is helping health plans deliver on their most advanced digital strategies.