Instead of continuing to add fixes on top of a broken system, healthcare needs to create a new, better system—a system built with a new kind of interoperability.
The foundation of every good business relationship is trust. It’s what enables strategic alignments and mutually beneficial outcomes. Without trust, each partner tends to focus on protecting their own interests, even at the other party’s expense. That doesn’t mean they can’t still collaborate on projects or processes, but they won’t be as effective if they’re always on guard. Lack of trust can also inhibit innovation, which can cause parties to settle for the status quo doing the minimum to continue–such is the case with healthcare payers and providers.
Friction between payers and providers has been around for decades and has grown from mere distrust to downright adversarial, much of it driven by a lack of transparency at the core. At first glance, this is understandable. Fraud, waste, and abuse cost payers billions each year, which is why they now employ more sophisticated technology to identify potential claim issues. However, this has led to a stark increase in denials and payer “takebacks” at a time when providers are already struggling with historically low margins.
Payers have implemented processes to reduce costs and eliminate unneccessary or inappropriate tests and procedures such as prior authorizations, medical necessity reviews, documentation requirements, and other complex processes. This has caused increased administrative work for providers and has negatively impacted patient care. In a 2022 survey by the American Medical Association, 94% of providers said the prior authorization process had caused delays in patient care, and 33% said those delays in care had caused a serious adverse event for patients.
On average, providers spend nearly two hours a day on documentation, which has played a significant role in provider burnout.
Another point of contention between payers and providers that promotes distrust is the inability to share data. Coverage is a prime example. Poor interoperability and data latency between provider and payer systems can cause extensive lags in getting updated information on multiple coverages or changes in coverage status. Most consumers switch health plans or have lapses in coverage multiple times throughout their lives (if not annually). Since benefits must be renewed each year, even if consumers don’t change carriers, they may still experience changes within their benefits plans.
Without data transparency and interoperability, sharing coverage data becomes a manual, time-consuming process, requiring providers to call insurers or search their websites to find the information they need. Even when they find it, there is no guarantee the information is complete and up to date, and incorrect or missing coverage information is one of the top causes of denied claims. Inaccurate data can lead to delays in care or cause patients to have to pay for a covered service. In these situations, distrust is extended to patients who may doubt that their health plan or provider has their best interests at heart.
The reality is that there may always be some level of distrust between payers and providers as each pushes the other to make things simpler and more transparent. The good news is that the tide is turning thanks to new technologies and solutions that eliminate the issues of transparency and interoperability and open a path for increased trust and effective collaboration. In fact, some of our country’s largest payers and providers are already well on their way and coverage is the first process they’re tackling.
Avaneer Health brought together some of our nation’s most renowned and innovative payers and providers to share their greatest challenges with the coverage and eligibility verification process. The discussion culminated with all parties working together to envision a solution that would address these challenges and lead to mutually beneficial outcomes—one of the cornerstones of building a trusting relationship. From those discussions, Avaneer Coverage DirectTM was born.
Coverage DirectTM conducts daily real-time, unsolicited coverage updates from participant source systems to identify misaligned data between one or more participants that provide services for the same individual. Participants are notified of updates so they can proactively remediate coverage discrepancies before, during, or after care – when the update occurs.
Coverage DirectTM reduces costs and administrative burdens for both payers and providers while also enhancing the patient experience.
Payers want to mitigate financial risk by ensuring members receive cost-effective, appropriate levels of care. At the same time, providers want autonomy around the decisions they make about their patients’ care, and they expect fair, timely compensation for that care. Both want to simplify the extreme administrative complexities caused by a lack of interoperability and transparency. With Coverage DirectTM, these goals merge to become a single shared vision, enabling payers and providers to work together to build a more collaborative, trust-filled, patient-centric future.
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