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Collaborative platforms drive health care efficiencies and streamline workflow


Easing provider-payer communications frees up resources for improving patient care

Health care providers face increased pressure to prioritize quality patient care while simultaneously serving as financial stewards of hospitals and medical practices. The daily administrative demands of interacting with a multitude of payers and their individual portals, a lack of standards and transparency, and a lingering reliance on outdated, manual processes continue to strain health care practitioners and their staffs.

In addition to burdening an already strained workforce, administrative tasks are costly. In fact, studies show that the health care industry could save $20 billion each year by reducing manual processes and adopting electronic administrative transactions.

Emerging cloud-based technologies are revolutionizing the way providers interact with payers, streamlining communication and collaborations, and optimizing care for patients by providing a secure, multi-payer platform that delivers vital administrative and clinical information to providers in real-time.

Access to health plans

Providers and staff devote a significant amount of time each day to navigating billing and insurance-related functions across numerous health plans. These tasks typically require lengthy phone calls, mountains of paperwork, and the pursuit of hard-to-locate data needed for completing a patient’s file.

By improving communication between physicians and payers, a network can facilitate payer-provider collaboration and align financial incentives, reduce administrative expenses, and boost levels of openness. Providers may have quick access to member and provider information that is both secure and HIPAA compliant using this platform, saving them the time and effort of having to independently track down this information.

Facilitating document exchange

Continuous document interchange, as well as communication between health plans and providers, is an essential component of the high-quality health care experience. Tech solutions can support this bi-directional exchange of information to reinforce vital clinical workflow by transmitting administrative, financial, and clinical information securely and in real time.

Examples of this type of information include fee schedules, risk adjustment information, quality measurement data, and performance reports. In addition, document interchange enables physicians to manage their patient panels by providing speedy and seamless access to clinical information such as patient summaries, high-risk patient lists, and care gap reviews.

Real-time membership verification and coverage information

Effective technologies centered on collaboration can simplify membership verification and coverage transfer for payers and providers.

On average, 28 eligibility and benefit verifications are required per member each year, which can create inefficiencies and logistical bottlenecks if not properly managed. Care delivery can be sped up with the aid of collaborative platforms that provide membership verifications, benefit coverage information, and patient payment responsibility. The latter includes information on copayments, deductibles, and benefits.

In addition, these systems can filter and apply specific plan search criteria, as well as define default data values and electronic data interchange parameters aligned with the requirements of the payers and the providers.

According to recent research, payers can save an estimated $9.8 billion annually by automating the workflows for determining eligibility and benefits. This frees up money for use in other crucial aspects of patient care.

Streamlining claims status inquiry and management

An estimated 168 million phone calls are made yearly between providers and health plans to verify claims status. Automated Claims Status Inquiry workflows eliminate these laborious calls by providing real-time access to detailed financial and claims status information.

Electronic workflows automate the delivery of claim receipt confirmation, adjudication status and payment details, allowing end users to view a claim’s status at any time and see all clam submissions, regardless of the submission method. These tools boost provider satisfaction by accommodating costly claim exceptions for numerous entities—from the largest provider practices to solo practitioners, transportation companies and amateur billers. In addition, they dramatically reduce costs by replacing paper claims, costly clearinghouses and health plan-subsidized submission software, editing claims to minimize rejections and saving an estimated $3.1 billion annually.

Simplifying prior authorizations

Streamlining prior authorization procedures is another important advantage of using modern payer and provider collaboration technologies. As the complexity of medical regulations, guidelines, and standards continues to increase, this process can become burdensome for payers, providers, and patients alike.

Surprisingly, only 26% of authorizations are electronic, which means the majority require tedious phone calls and time-consuming paper claims. Retooling these laborious manual processes into a streamlined electronic format with digital patient data reduces administrative tasks considerably.

With the appropriate digital tools, automatic requests and applications can be made for the exchange of clinical, financial, and administrative data in real time. This allows providers to have access to the most up-to-date information regarding medical status, approvals, and denials, which in turn enables a greater focus on patient care.

Electronic collaboration between payers and providers from beginning to end ultimately increases workflow efficiencies and provides integrated data resources that are current, user-friendly, and intuitive across the entirety of the health care spectrum. When communication flows freely and ambiguity is removed, the results are increased efficiency and precision for the benefit of the patient.

Lisa Hebert is senior director of product management at NantHealth, where she leads the product management team for NaviNet, a leading payer-provider collaboration and engagement platform

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