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Is the payer/provider model like playing monkey in the middle?

Aug 11, 2021 | Admin, Health and Life Sciences, Healthcare, Latest News

Most would agree that moving our healthcare delivery systems toward a customer-centric, results-focused model is a good thing. But achieving a seamless patient experience has its challenges as payers and providers find better ways to organize and share essential information through existing processes. 

This need for a more comprehensive overview of data sometimes feels more like playing monkey in the middle; some stakeholders are left out of accessing information while others have the information but aren’t using a system that makes it possible to share it with other parties. 

The key to an effective payer/provider relationship is a two-pronged strategy based on better data collection and collaboration. Here’s why. 


Improving data collection and exchange

Most people have a primary care physician. Should the need for specialized care arise, the PCP will refer the patient to another healthcare provider (and sometimes another in addition to that). 

When each healthcare provider relies on their own workflow, such as using hard copy patient files and test results or inputting patient information like medications or treatments with basic software, the patient lacks a comprehensive overview of their health. These gaps in a patient’s treatment history impact the quality of care. 

Moreover, a lag in data reporting to the payer delays claims processing times and may cause confusion should the patient or provider have questions about costs. 

This sounds expensive as well as inefficient—and it is. Experts estimate that the US spends around $812 billion just on healthcare administration costs. 

“Administrative costs are so high because thousands of insurance companies individually negotiate benefit rules and rates with thousands of hospitals and doctors,” explains Diane Archer. “On top of that, they rely on different billing procedures — and this puts a costly burden on providers.”

At a time when stakeholders are pressured to adopt a patient-centric care delivery system while streamlining costs, digital technology is providing the solution. For instance, almost 86 percent of office-based physicians use an EMR/EHR system. This move toward interoperability is opening the door to better collaboration.  

 “Providers are looking at integrating their information systems better. So where it has to go is that collaborative piece,” says Loren Mann, “Payers are realizing that the more data they share with providers, the better the outcomes.” And in that context, predictive analytics will become far more widely used.”

Among the advantages, implementing an automated system that integrates with mobile EMR devices or other digital-based patient data systems promotes transparency, trust, accuracy, accessibility, and reduces the risk of delays in claims processing. 

This technology also empowers the patient by providing an active role in their care. As providers collect patient data using EMRs, patient portals and other self-service tools encourage patients to access their files and input data as well. One study found that when this technology is available, one in three people track their health care charges and costs with a computer, smartphone, or other electronic means.  


Collaboration is key

Sharing real-time, comprehensive data by using an intuitive, automated system opens up innovative possibilities to improve not only the delivery of patient care but enhance the overall patient experience. 

For instance, when the provider’s processes align with those of the payer based on shared data and care models, providers can be confident that their treatment decisions are supported by the payer and meet compliance guidelines. 

As the payer/provider model evolves and patients become more involved in shared medical decisions, some of the benefits of this shift to better collaboration show improved transparency, standardized data, and fewer denied claims. 


Better transparency between payers and providers creates an improved understanding of treatments, patient history, exams, etc. In turn, payers can institute processes that shorten processing times, streamline billing, and reduce denied claims. 

Standardized, shareable data

The advantages of having consistent patient data reporting extends beyond streamlined billing processes, and patient care. A broader perspective shows the importance of gathering accurate and consistent data that supports research, health trends, regionally-based health conditions, new treatments, etc. This results in transformative treatments and improved patient care within different organizations. 

Denial management: One area with continual impact on the payer/provider relationship is the rising claims denial rate placed on healthcare providers. Studies show a 23 percent increase in the number of claim denials hospitals received in 2020 compared to four years previous. 


A recent survey found that 85 percent of claim denials could be avoided with better processes, such as medical coding and billing procedures. Another healthcare analysis supports this finding, adding that “strategies such as staff education and automation of front-end steps can help hospitals prevent common reasons for claim denials, which include coordination of benefits, benefit maximum, and plan coverage.”

As healthcare systems adapt to the often complicated and evolving needs of stakeholders, it’s easy to leave a valued player out of the game. The most reliable model moving forward is one based on a transparent, collaborative working model that routinely collects and shares accurate information that streamlines processes while improving patient care. 

“Payers and providers can use enabling technology, workflow tools and analytics that drive good decision-making to share information,” says Mitchell Morris, MD. “Each should be comfortable with what the other is doing,” 



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