Getting Coverage Right Takes a Team Approach

We’ve heard for years about the friction between payers and providers—friction that stems from a lack of transparency and trust. Providers want autonomy in the decisions they make around caring for their patients, and they expect fair, timely compensation for that care. At the same time, payers want to reduce the billions in fraud, waste, and abuse they experience annually, while also ensuring their members receive the most cost-effective and appropriate level of care. These priorities shouldn’t negate one another, but without transparency and trust, the friction will continue to grow.  

One of the most significant manifestations of the lack of transparency is denied claims, which have become a top concern of healthcare leaders, and rightfully so. Payers are denying a record number of claims. According to a 2023 report by KFF, “nearly 17% of in-network claims were denied in 2021.” However, denial rate averages range from two percent to 49%. The puzzling fact is that more than half of denials are eventually overturned, which means they should have been accepted and paid the first time around, before providers spend extensive resources on multiple appeal attempts.  

70% of healthcare leaders surveyed say reducing denials is their top priority and of even greater importance than before the pandemic. 

The bottom line is that denials are a point of contention fueling a disjointed healthcare system and driving up costs. Besides impacting revenues, denials also affect patients who may experience surprise bills for a service that was covered. When this happens, patients may put off future care to avoid further medical costs. Of course, when patients put off care, their conditions can worsen and lead to costly hospitalizations, emergency room visits, and poor outcomes.  

 More than 25% of adults in the U.S. say they have delayed or put off “medical care, prescription drugs, mental health care, or dental care” because of the cost. Another 15% skipped care or didn’t fill a prescribed medication for the same reason. 

Getting to the root cause 

While there are multiple reasons a claim may be denied, incorrect eligibility and coverage information is one of the top reasons. This is understandable considering how often individuals change their insurance throughout their lifetimes. Even when the carrier remains the same, annual renewals allow individuals to change their plan options, which often includes changes to co-pays, deductibles, and network options. This is why providers check coverage multiple times, even for the same encounter—at registration, check-in, and prior to claim submission.  

The volume of eligibility and benefits verifications increased by 18% between 2022 and 2023 and now accounts for 54% of all medical administrative transactions—the highest of all administrative transactions. Spending on eligibility and benefits verification increased by 60% to $43 billion annually.  

Here is where we circle back to the issue of transparency. Today, providers need to do manual work, call payers, or search their websites in an effort to capture up-to-date coverage information. Some providers have entire teams devoted solely to this effort. Even when they find information, there is no guarantee it is complete or up to date. The process is highly manual, time consuming, and a significant burden on both payers and providers, especially with staffing shortages as they are. This inefficient process can also lead to delays in care and poor outcomes while also extending payer-provider friction to patients who may question whether their provider or insurance plan has their best interests in mind. 

Implementing a team approach 

The idea of payers and providers working seamlessly together may seem unfathomable. Fortunately, that is no longer the case. We now have innovative new technologies that eliminate the issues of transparency and clear a pathway for mutually beneficial collaboration. This team approach puts the patient at the center and helps lower costs and create greater financial viability. 

Avaneer Coverage Direct^TM enables greater transparency,  seamless data sharing, and better collaboration between payers and other providers. This team approach provides a more complete picture of a patient’s coverage and final financial responsibility, reducing denials and improving the patient experience. 

How it works 

Avaneer Coverage Direct is a part of the Avaneer NetworkTM, which connects payers and providers directly, allowing real-time, secure data exchange without the need for third parties. The solution automatically determines coverage changes or missing, conflicting, or incorrect coverage details and sends immediate updates to all permissioned providers and payers. Providers benefit by receiving a proactive feed of patient coverage into their electronic health records (EHRs), improving the patient experience, and reducing first-pass denials. Payers benefit by receiving real-time coordination of benefit (COB) leads and visibility into data discrepancies. Providers can save between $3.36 and $5.75 per claim, while payers can save between $0.57 and $1.65 per claim.  

With Avaneer Coverage Direct, data remains under the control of data owners and never has to leave that organization’s systems, which increases security and eliminates the need for need for third-party involvement.  

Teamwork makes the dream work 

It’s time for payers and providers to work together to improve outcomes, lower costs, and create a better patient experience. Avaneer Coverage Direct is the answer. By promoting transparency, seamless collaboration, and shared priorities, Avaneer Coverage Direct can help make friction a thing of the past.