Payers and Providers: Partnering for Better Outcomes

By Austin Ridgeway,  Director of Sales Support and Business Development, HGS Healthcare

The healthcare industry has experienced unprecedented change in recent years. Technological efficiencies and strategic service offerings, value-based care initiatives, and federal and state mandates have converged with the goal of creating a system that is patient-centered and outcomes based, while also lowering the overall cost of care. This paradigm shift has made it inevitable for healthcare stakeholders to collaborate. More importantly, payers and providers are increasingly transparent and aligned toward better patient outcomes. As one example, the HITECH Act and mandates around quality reporting initiatives have paved the path to transparency for better data tracking and reporting abilities across payer and provider systems. Payers Providers Collaboration

Barriers to Collaboration

How can payers and providers collaborate? Let’s take a look at data. The amount of data attached to every patient has grown exponentially—and all of it has to be gathered, integrated and interpreted according to compliance guidelines and processes that can vary widely between payers and providers, as well as between jurisdictional boundaries. Additionally, the datasets held by payers and providers can be different. For example, payers possess data on claims, financial analytics, and risk models. Providers have administrative and clinical data that includes case histories and outcomes. Each data set is valuable, but in isolation doesn’t provide a holistic and contextual perspective of the patient. Providers need to leverage health plan data in order to move from episodic care to delivering outcomes-based care across the care continuum. Payers need access to patient information in order to work with providers to establish appropriate care plans for their members. In the past, both stakeholders have attempted to bridge these data gaps through costly manual processes, which has resulted in enormous costs. According to the 2016 CAQH Index report on healthcare’s adoption of electronic transactions, the administrative costs of closing those data gaps consumes nearly $300 billion per year—about 15% of all healthcare expenditures.

Data Management

Health plans are spending millions of dollars to generate analytics on members who are high risk and high cost. They want to be able to synthesize these data sets and share it with providers to help patients. While there is no shortage of data in healthcare, much of it is segmented. This obscures the complete portrait of a population’s health and makes risk adjustment exceedingly difficult. Another data management problem is redundancy. Though many health plans separate risk adjustment activities from HEDIS, Medicare Star rating system and care management activities, they all need the same patient medical record, forcing providers to dedicate significant financial and administrative resources to respond to seemingly duplicative requests with few guarantees that the information they are procuring is timely and accurate.

Claims, Coding, and Billing

Prior authorizations, patient eligibility, benefits screening, and other utilization management processes represent a significant financial and administrative burden for providers. According to a 2017 article by Becker’s Hospital Review, denied claims (of all types) for large hospitals (250-400 beds) can be as high as 7% to 10% of the hospital accounts receivable. This can cause intensive resource allocation to appeal denied claims and significant revenue leakage due to forgoing the appeals process. Compounding the problem is the fact that most of these claims processes are manual, rather than electronic. Both payers and providers spend a great deal of time approving these requests or communicating essential information about changes to reimbursement processes by phone, fax, and even postal mail. This inevitably leads to greater inefficiencies and administrative burdens, lower reimbursement, and unnecessary treatment delays for patients.

Patient/Member Services and Experience

Along with value-based care, patient-centric care is one of the major pillars of healthcare reform efforts. Entities such as accountable care organizations, in which reimbursements are ties to quality metrics, are driving an increasing number of payer and provider collaborations. Additionally, the ubiquity of digital communication channels, increased financial responsibility on the part of patients, and developing markets in the areas of telehealth and evidence-based care has made personalized, consumer-friendly access to information—from insurance benefits to health records—a growing necessity for both providers and health plans. It’s clear that the legacy systems and department silos that shaped many health insurance and provider organizations over decades are no longer optimized to drive success in today’s consumer-centric environment. The millions of new potential customers and increased competition in the market are compelling these organizations to implement efficiencies and innovations that tap into connected customers.

Collaboration Opportunities

Process decisions such as strategic automation and partnering with skilled healthcare business process specialists can make a significant difference in payer-provider engagement and simplification of prior complex work flows with mutually improved outcomes. Processes such as strategic automation and business processes outsourcing can make a significant difference in payer-provider engagement and transparency, as well as the cost of doing business.


Payers and providers each possess patient data that when put together not only provides a more holistic view of the patient/member’s care experience but also allows providers and health plans to identify opportunities for more cost-effective and outcomes-based care strategies, particularly for high-risk populations. Automation reduces or eliminates manual processes for many tasks with data-intensive processes, across multiple domains and verticals. Automation can drive tremendous accuracy while simplifying a much more robust view of our patients, members, and customers’ unique healthcare needs. Effective automation relies on good business process design, with multiple factors to consider, including systems use, business impact, data touchpoints, ROI of labor, and investment. And the ROI—from the front office and the back office—is significant. For example, robotic process automation (RPA) reduces or can even eliminate the manual effort required for many activities or tasks. RPA doesn’t require back-office integration through application programming interfaces (APIs) and seamlessly works with end-user interfaces and enterprise applications. These system-agnostic solutions work well with data-intensive processes, across multiple domains and industry verticals.

Business Process Outsourcing

Once regarded simply as a corporate cost-cutting strategy, today’s BPO organizations are bringing strategic thinking and innovation to the modern challenges facing healthcare, including data management and integration, consumer-centric services, predictive analytics and process automation. BPO organizations can offer both payers and providers such services as: Process Optimization. An experienced BPO partner will examine all the options to determine the best course of action. This may mean eliminating or revising a process (or parts of it) rather than simply applying technology to make an inefficient process more efficient. Capability Enhancement. Another overarching reason to partner with a specialty BPO organization is to quickly acquire knowledge and/or skillsets that do not currently reside within the payer organization. Rather than expending time and resources to get internal personnel up to speed, or going through a drawn-out hiring process, a skilled BPO organization can bring that knowledge or those skills to an organization immediately with limited lead time. Ultimately, the goal is to develop a partnership which brings the talent, best practices and resources to the table. The key to building this successful relationship begins with the selection of a partner that shares the organization’s vision, and one that has a proven track record of successfully executing on that vision.