Conquering Provider Abrasion by Building Trust in Your Payment Integrity Program

Remember that record scratch we previously discussed?

Well, there’s more to the story…

Now that you know the record is scratched, what do you do about it?

Just keep playing it and let it get stuck in place on the endlessly scratchy loop?

Remember where the scratch is and bump the needle so it continues to play?

Toss it out and never listen to the record again?

Buy a new one?

Most people would likely agree that the option to just keep playing it and deal with the endless loop is the least viable option. Yet when it comes to Payment Integrity and the provider abrasion that often accompanies it, the option to just keep doing the same thing and getting stuck in the endless loop is often the path taken.

In a traditional Payment Integrity program, leads are generated, cases are opened, worked, and closed. Outcomes are tracked in some fashion. Perhaps it’s number of cases closed, case turnaround time, or dollars recovered. But there is another metric that exists, yet it can be difficult to quantify – provider abrasion.

Provider abrasion often occurs as a result of false positives that lead to the same provider being the subject of a review multiple times, yet the end result of the review is the provider did nothing wrong. Often, these false positives are a result of issues with data, configuration, lack of adaptability, and operating in silos.

In some instances, providers are subjected to multiple, concurrent reviews from different areas of the organization. It is often compounded by being subjected to the concurrent reviews across multiple payers. This can be extremely confusing for a provider who may wonder why they pass a review without any issue yet a review of claims from the same time period from a different group within the payer’s organization or a different payer may result in a recoupment. Providers who are subjected to this pattern of review get frustrated and oftentimes will either threaten to or actually leave the network creating a gap in network adequacy.

Imagine if there was an ability to reduce this payment integrity-related provider abrasion.

Rather than have these interactions with a provider be a source of abrasion, they could be opportunities to build provider trust in your Payment Integrity Program.

For example, if your payment integrity platform is generating accurate information and helping to identify the highest-risk providers, those under review may still express some frustration with being the subject of a review, but when the outcomes support the initiation of the review, there will be less for the provider to be upset about.

When providers trust the information and the process that led to them being selected for a review, they react differently. Likewise, they are more receptive to the outcome of the review and will likely address the issue that caused them to be the focus of the review.

The ability to leverage the payment integrity process to engage with the provider and build trust in your program should be one of the goals of the process. The providers who do not address the issues identified will continue to be the subject of reviews and are likely candidates for removal from the network.

The foundation of a trusted Payment Integrity Program is to have real-time and accurate information at your fingertips at all times. This information allows for proactive monitoring of provider billing practices and changes over time which can be accomplished by leveraging technology. Some of the capabilities that enable this monitoring and tracking include using drill-down dashboards, automating the process of sending information to providers, and tracking the prevented loss associated with provider engagement.

Drill-down dashboards – Having drill-down dashboards allows for a more in-depth review of the provider and associated billing practices. Understanding why the provider is high-risk is the key to determining what corrective action may be necessary and to having a meaningful engagement with the provider. Can your payment integrity platform drill-down multiple levels to provide sufficient detail to figure out what problem may exist and identify the practice that needs correcting?

Large-scale information distribution – When multiple providers are exhibiting the same inappropriate billing patterns, manually generating individual letters can be extremely time consuming. As a result of resource constraints, not all providers identified may be selected for review. The providers who are not engaged in the review process will continue to be a risk to the organization. Does your payment integrity platform allow you to send out information to any number of providers concurrently with the click of a button?

Tracking prevented loss – Once the engagement with the provider occurs, the billing patterns may begin to change. When the change occurs, automatically tracking the post-engagement billing practices can provide the payment integrity program with insightful information on the effectiveness of its communications with the provider. Does your payment integrity platform automatically track this information and make it available for reporting?

While not every review results in a recovery, by identifying the right providers for review and building provider confidence in your payment integrity program, provider abrasion can be significantly reduced. The key is to ensure your technology platform supports accurate identification of providers and subsequently allows for tracking the outcome of those interactions on provider billing practices. With this additional data point of prevented loss associated with payment integrity efforts, your program can introduce an additional metric in reporting its overall effectiveness.

The road to a trusted Payment Integrity Program is a journey. It is also a two-way street – building trust within your organization and within your provider network. The key to building trust and reducing provider abrasion starts with the accuracy of the leads being generated and the consistency of that accuracy over time.