Good relationships result when people understand and respect each other’s point of view. This is certainly true when it comes to payer-provider relationships. Spending time learning about payers and the challenges they face can not only help providers appreciate the payers’ perspective, but also allow the provider to effectively meet the payers’ requirements.
In the existing third party reimbursement climate, the payer is a member of the healthcare team. The payer’s role includes selecting and contracting with qualified providers, offering a product and provider panel to employers, and processing and paying claims for plan enrollees. Payers are not in the business of deciding what services may or may not be appropriate for a particular patient.
Unfortunately, providers sometimes look to change payers rather than understand them. The reality is that payers are not going to change until it is mandated they do things differently. Whether or not you agree with a payer’s policies and strategies, you do need to follow them in order to get paid.
Providers should put their energy into learning everything they can about each of their major payers and implementing the payer’s policies and procedures accordingly to ensure minimal problems with reimbursement. Healthcare reimbursement is a complicated system that can be a maze for providers, but the sooner you accept that there is no choice but to follow the payer’s rules and regulations to get claims paid, the sooner you will see cash flow improve.
To best manage payers, providers must have an experienced, skilled and knowledgeable staff. It may be beneficial to assign specific staff members to particular payers, so they can educate themselves on the payer’s requirements, build a relationship with the payer and ultimately recognize the nuances of the payer’s rules.
In addition, practices should design each part of the revenue cycle—from eligibility verification through denials management—to enhance workflow, support accuracy and streamline operations. The more efficiently and effectively you operate your revenue cycle, the more likely you will limit issues with payers.
One final thought, if you have ever a question about a payer’s requirements, you should ask them. While this may seem obvious, practices that don’t have a relationship with a payer may find this daunting. Building relationships, asking questions and working as a team are all necessary to reap the benefits of strong payer-provider interactions.