THE 'EDGE REPORT BLOG

Provider Satisfaction: A Consistent Pain Point for Health Plans

Just about every health plan that I have talked to in my career is currently experiencing, or has had experienced, problems keeping their provider population at a high level of satisfaction. Accurate provider data matching is a great example of a consistent pain point for health plans that contributes to lower provider satisfaction, no matter the health plans' size or solution. If a health plan cannot match a provider accurately through integration for provider data management or claims processing, payment delays or incorrect payments occur.  

What I have seen is, without the right integrated solution, something as simple as an accurate, reliable provider match can drain a payer's time and resources. Incorrect payments lead to appeals, disgruntled providers, phone calls, the need to rework and reprocess claims, and ultimately negatively impact the bottom line driving up the precious PMPM that all health plans live and die by.

Worse yet, many other factors can impact the claims payment process, whether it is human or system error, unpredicted provider billing behaviors, or even outdated technology stacks. The myriad of issues like unprocessed authorizations, incorrect benefits, or pricing, missing electronic medical records, or lack of payment integrity and payment accountability are just some of the problems health plans experience daily. Customer service teams, provider appeals, and adjusted claims drive increased overhead and decreased provider satisfaction as a result.

With the right technology, health plans can use a provider-focused ecosystem leveraging advanced analytics to track provider satisfaction and work to understand different characteristics related to billing and claims administration. Actionable data can enable operations staff to put issues into context to adapt their business, introducing new pricing and reimbursement models accordingly. My colleague Diane Pascot recently published an excellent blog on the value of analytics, Leveraging Real-Time Data for a Meaningful Customer Experience.

Health plans have discovered one obvious key to provider satisfaction is having a solution that automates and accurately matches providers, which is also key to high auto adjudication rates (arguably the most valuable statistic, next to accuracy, for any given health plan). Additionally, they understand how accurate payments lead to lower administrative costs and overall increased satisfaction. For health plans, while it is critical to keep persistency in their membership, so is maintaining high levels of provider satisfaction. The most successful clients use a comprehensive, integrated ecosystem that can provide the best-of-breed in care management, pricing, clinical edits, and analytics that increases both provider payment accuracy and satisfaction.

About the Author

Dustin Rojas

Dustin Rojas, Senior Director of Sales Engineering and Strategy, HealthEdge
LinkedIn
drojas@healthedge.com
Dustin Rojas is a senior healthcare technology professional with deep expertise and extensive experience in many aspects of Healthplan Operations, and the Payer Software industry.  Dustin primarily focuses on collaborating with the Sales team and the overall organization to lend his collective experience to the achieve the overall strategic goal of "Crossing the Chasm.”  As Senior Director of Sales Engineering and Strategy for HealthEdge, he regularly works with Prospects and Senior Leadership to assist in current sales pursuits, in addition to collaborating and consulting on emerging services opportunities.  Prior to joining HealthEdge in 2019, Dustin spent 22 years in a variety of roles in the healthcare payer space with organizations that include Great-West Healthcare (Cigna West), and Cognizant/TriZetto.

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