Evaluate Payer-Provider Portals on These 4 Features

Evaluate Payer-Provider Portals on These 4 Features

Go beyond the basics with a payer-provider portal that drives engagement and decreases costs.

How would you characterize the health of your relationships with network providers? If yours is like many health plans, those relationships could always improve. And providers agree, with a relatively high number of them reporting low levels of trust in public and private payers. Without collaboration, the shift to value-based care and the coronavirus crisis could push these strained partnerships beyond their limit. But payer-provider portals may provide an answer to this dilemma. Increasingly, health plans are using them to come together on claims payments and other communication needs.

How to Choose a Payer-Provider Portal

When providers rank top payer performers, they reveal a link between efficiency and trust. Those health plans that simplify claims processing, offer transparency in their transactions and are quick to reimburse will win these relationships. With these goals in mind, we identified 4 features your payer-provider portal must have to drive engagement and increase revenue.

1. Overpayments and underpayments

Both health plans and providers want a clean claims process that reduces the administrative burden and speeds reimbursement. The current process at most payer organizations relies too heavily on paper-based, manual activities that lack context and create abrasion. Portals provide the opportunity for two-way, real-time secure communication that eliminates the need for fax and mail.

At the most basic level, your portal should support both health plan auditors communicating on overpayments and providers reporting underpayments. Providers need to quickly see the status of all claims, including visibility on medical records requests and details on denials and appeals – down to the line level. Form letters don’t include this context, requiring follow-up phone calls that add even more inefficiency to the process. But combined with alerting for claims that need input, the payer-provider portal workflow accelerates audit resolution.

2. Credit balance, recovery posting and reconciliation

A recent survey confirms providers find revenue cycle management most in need of innovation and disruption. But they also said lack of alignment between healthcare stakeholders – including payers – could stifle progress on this front. Payer-provider portals hold the potential to ensure clean accounting systems for both sides of the equation.

For providers, an at-a-glance view on their total claims with you, broken down by those pending, accepted, denied and in review is essential. They also find value in the ability to identify and resolve credit balance issues. As providers accept denials, this should automatically initiate recoupment and recovery on the payer's side to ensure full overpayment tracking and reconciliation with no gaps. This seamless process should extend to unsolicited refunds as well.

With all of these activities connected, payer auditors get a view on the net recoveries and claim spend in real-time. Full analytics on the effectiveness of these activities – reports, dashboards and a payment forecast – increase this value.

3. Seamless integrations

Providers – like many in healthcare – operate with arguably too many siloed tools. They may already use multiple portals to work with various payers. Many health plan auditors work in a similar environment. Jumping in and out of several disconnected systems wastes time and leads to mistakes. But payer-provider portals that minimize additional burden on this front benefit both sides of this relationship.

For providers, the ability to connect the portal with their EHR allows for increased efficiency on medical records requests. They can see helpful information from both sources at their fingertips and quickly access exactly what they need for each task for faster, more reliable processes. For auditors, keeping the portal on-platform with their current auditing workflow minimizes repetitive tasks and speeds turnaround times. This integrated framework is especially useful for the accelerated timelines of prepay audits

4. All-in-one information access

Think of all the different ways you communicate with providers and deliver information. And yet, over 30% of providers report not communicating with payers at all. No wonder providers and payers both feel these relationships lack alignment. With information constantly changing, the payer-provider portal holds potential to act as a single source of truth.

Use the portal to distribute always-up-to-date provider manuals, procedures, correspondence, newsletters, how-to guides, and other provider education and communications. In return, providers don’t have to manually complete forms and figure out how to submit them or worry that out-of-date information will prevent timely claims payment. With dashboard notifications that promote self-service, providers and health plans can stay on the same page.

Pareo Payer-Provider Portal Increases Engagement and Revenue

The relationship between health plans and providers requires more collaboration than ever. As our industry shifts toward transparency, you need a technology platform that supports that goal.

A payer-provider portal like Pareo Provider can help you demonstrate value on the fundamental communication needs of claims payment accuracy. Reduce the administrative burden. Make it easier to respond to medical records requests. Provide context on claims overpayment submissions and respond quickly to underpayments. Increase efficiencies for health plan auditors and revenue cycle managers alike. This foundation of trust paves the way to coming together on initiatives of greater strategic significance like value-based care.


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

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.

A 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.


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

Health Plans Return to Payment Integrity

Health Plans Return to Payment Integrity

3 claims trends associated with the healthcare industry getting back to business, and how health plans can smoothly resume payment integrity efforts.

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?


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

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.

Bundled payment
Pay-for-performance / Shared savings
Blended payment

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.


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

Modernizing communication with providers

Modernizing communication with providers

Time to move past playing telephone with providers. Here’s a better communication strategy for health plans.

By relying on fax machines and snail mail to communicate overpayments, underpayments, denials, and just about everything else, the payer-provider relationship sometimes looks like very dysfunctional pen pals. The cost of managing this unwieldy process is too high for both parties, but new options for electronically communicating are emerging. Here’s a candid look at how your health plan can modernize its approach to provider communication.

What solutions have been proposed to improve payer-provider communication?

Remember the grade-school game of telephone? You sit in a circle and pass a message around by whispering it into the ear of the person next to you. Then the last person has to say to the group what they heard and often, the message varies hilariously from the original. What’s been happening between payers and providers isn’t all that different, only it’s not very funny.

There are real costs and consequences associated with poor communication. And besides, moving away from telephone conversations is considered a first-step solution to improve provider communication. So what’s replacing phones and fax machines?

Two solutions have emerged as leaders in the effort to improve traditional communication problems: the Blue Button initiative and electronic payer-provider portals. Each is complex in its own right but are summarized below:

    • The Blue Button initiative was introduced last year and aims to provide greater access to claims data. Several ONC/CMS proposals have been issued to promote health data sharing, more broadly, across healthcare organizations. These initiatives tend to be more focused on healthcare point-of-care decisions, though, rather than getting paid. Recently, CMS announced the Medicare Blue Button, a pilot program planned for launch next month. Other data sharing initiatives involving APIs have also been recently announced.
    • Electronic payer-provider portals are solutions more focused on communicating about claims: overpayments, underpayments, denials, prior authorizations, medical records documentation. Last year, CMS administrator Seema Verma stated she wants physician fax machines gone by 2020, replaced by digital health information exchange. But to be effective, digital health information available via portals should be all-electronic, real-time communication in order to truly drive engagement and efficiencies.

What’s clear is that outdated methods of communicating between payers and providers will no longer suffice, either due to regulation or market demand. Furthermore, in order to meet consumer demand, payers and providers have to find a better way to share data.

“People die because we don’t provide access to data in a real-time basis. The most important thing we can do is figure out how to coordinate that care in real-time so we can directly impact and save lives,” says a leading Blues plan president and CEO.

Where does Pareo® fit in?

Pareo is a technology solution for health plans that fosters improved communication with providers through native, built-in tools. By automating some communication needs, streamlining others, and eliminating errant messages entirely (such as duplicate medical requests), Pareo allows health plans to make strides in digitizing health communications with providers. Importantly, a communication and engagement module like ours can serve to bridge the gap between data sharing and actually getting paid (something payers and providers alike appreciate).

Pareo enhances Provider Communication efforts through:

  • Faster payments with less manual intervention
  • Improving trust/NPS with providers
  • Facilitating alternative payment models
  • Growing recoveries

Payers need a way to see the bigger picture — a way to aggregate data and make informed decisions quickly. With an electronic provider communication mechanism in place (like Pareo), data sharing initiatives like Blue Button and APIs become actionable ways to move the needle and, even more importantly, save lives.

Talk to ClarisHealth about how Pareo®advanced payment integrity technology is helping health plans successfully implement their digital-first strategies. 

Prepare to Meet the Future with Data

Prepare to Meet the Future with Data

We revisit ONC’s Information Blocking Rule, recap public comments, and look at how health plans can meet data sharing  requirements.

Earlier this year, we wrote about the ONC’s proposed information blocking rule and how it serves as an opportunity for health plans. The proposed rule faced a public comment period (which closed last month) during which major industry concerns were voiced. The consensus by many seems to be that ONC’s rule lacks clarification in key areas while inadvertently increasing complexity (and cost) in others.  

But as they say, “the writing’s on the wall” for health data interoperability and broader access to electronic health information. Where does this leave health plans? A recent study by Deloitte predicts that healthcare organizations are standing at the precipice of innovation. But first, let’s look at the feedback that the proposed information blocking rule received.

Industry Response to the Information Blocking Rule

One thing we can agree on at this point: interoperability is a major objective for our industry. But those who would be affected by the Information Blocking Rule have asked the ONC to revise or even revoke the current rule. This includes the Federal Trade Commission, who despite being consulted on the proposed rule, issued a letter asking the ONC to consider refinements. Notably, eHealth Initiative (eHI) offered the following comments and concerns

Scope of “Electronic Health Information” is too broad, should be defined

Conditions and Maintenance of Certification (APIs)

 Too complex and costly as proposed

 Too much risk to providers and patients, specifically the proposed “Click Yes to Continue” model does not adequately portray data security risk to patient

 Information Blocking

 Healthcare actors should be defined in the final rule

 Complex and costly documentation requirements

    Greater Data Sharing is the Goal

    The ONC has stated that greater interoperability is the goal of the proposed Information Blocking Rule. Improved data sharing is a worthy objective for health plans because it’s an easy effort to prove value on. Health plans have a competitive edge over their counterparts when they are more integrated with providers and members. In addition to priming plans to be compliant with whatever final rule is based, improving access to data is also key to readying for other initiatives, such as alternative payment models

    Of course, we know that total healthcare data interoperability sounds like the answer to all your challenges. But once the hard work begins of solving this problem, it can feel like data sharing at the level required is next to impossible. We’re here to tell you it’s not; interoperability is a realistic goal with the right technology

    Let’s frame the objective of the ONC’s Information Blocking Rule in a more approachable way: Healthcare stakeholders need real-time, accurate and contextual data access. And the real challenges? Healthcare organizations still struggle with interoperability, largely due to issues like administrative complexity. Messy (as in, unstructured) or missing data is still a problem as well. 

    We know that our industry is on the precipice of innovation. The recent study from Deloitte referenced above and in our prior article posits healthcare is on the precipice of a “20 to 30 year industry transformation. The industry forces and the disruption that's upon us are true indicators that we're going to be going through a cycle of innovation.” Innovation made possible by radical data interoperability. 

    ONC’s Information Blocking Rule has 7 exceptions. Do you know what they are?

    See the official list here.

    The Promise of Big Data

    Improved access to data is considered a consumer-driven shift, one often compared to the Amazon experience where a consumer can have on-demand access to personal information. But getting personalized, real-time electronic health data at the click of a button is a lot more complicated than it sounds. And it requires a special relationship that has historically been difficult: high-level collaboration between payers and providers. 

    Yet this demand is exactly the kind of opportunity health plans can seize upon as they search out competitive ways to utilize big data. Examples can be seen in the use of predictive analytics to mitigate risk, noted in this article as a “massive moneysaver” by one health plan who made a big IT investment. Reams of data are available to health plans — all that’s lacking is the right way to connect and analyze it. 

    “Improving relationships with members and providers is already a focus for health plans, and data sharing is another way to accomplish that goal.”

    Health plan of the future? It starts with data sharing.

    One way of looking at the Information Blocking Rule is that it’s a proposed answer to a problem that health plans can take control of now. Improving data sharing isn’t just a proactive approach to anticipated regulation — it’s becoming an essential business function for health plans. To get started, health plans can focus on these three areas: 

    Develop data analytics and predictive modeling know-how

    Take advantage of opportunities to break down data silos by fostering relationships with providers, members and vendors

    Look for existing technology that can support these goals: bring disparate data together, simplify data modeling, and provide a transparent communications platform

    The future of data sharing is now. Pareo® is how.

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