Policy & Regulation News

How does the ACA Impact Providers’ Trust of Payers?

By Jacqueline DiChiara

- How are those healthcare payers participating in Affordable Care Act (ACA) implementation performing? Perhaps pretty well, according to a tenth annual PayerView report card and ninth annual Payer Trust Index released consecutively by athenahealth and ReviveHealth.

affordable care act

Provider trust of payers remains dismal within the healthcare industry. There is a vital need for increased transparency and communication, according to athenahealth’s key findings on 166 healthcare payers, ranking such elements as denial rate, first-pass claim resolution rate, and provider collection burden.

Laurie Graham, Payer Operations Manager at athenahealth, spoke with RevCycleIntelligence.com about the currently evolving circumstances regarding payer performance and perception.

In terms of where healthcare payers should be best focusing their collective efforts, Graham says provider alignment is an essential ingredient to operational efficiency required for taking on new areas of innovation. Such areas include population health, telemedicine, value-based reimbursement, and regulatory changes like ICD-10.

“Payers historically have prioritized growing their membership, containing medical cost and reducing operational costs while managing government contracts and increasing pressure from taxes, fees and medical loss ratios,” Graham explains. “Payers ahead of the curve are thinking about ways to streamline their administrative processes as much as possible and creating consumer engagement at the same time,” she maintains.

If payers pivot to meet the demands of an evolving regulatory environment, they will succeed, says Graham. Likewise, if payers remain focused on provider alignment throughout change, then they can more efficiently streamline their operations and meet more of their goals, Graham states.

“New operational efficiencies are needed to address traditionally non-automated areas, like provider enrollment, credentialing, pre-authorizations, pre-certifications, and referrals. These processes require phone calls, paper forms, faxes, emails, and portals that could be replaced with standard transactions. The result is a much more efficient, scalable, and accurate process for the supply chain. The payer, provider, and patient all benefit from standardized administrative efficiency,” Graham states, confirming the advocacy for more transparency between payers and providers.

Payers shouldn’t be afraid of change. For example, there have not been significant operational challenges for the majority of healthcare payers following ACA implementation, confirms Graham, in reference to athenahealth’s PayerView and ReviveHealth’s payer report card.

Graham says that although ACA implementation had variable impact to payers by state, the report did not reveal operational performance problems for payers that participated in Medicaid expansion and health insurance exchanges.

“There was concern that the overwhelming enrollment of individuals into Medicaid expansion could potentially cause operational slowdown or operational performance problems,” Graham explains. “We actually saw Medicaid expansion states continue to perform pretty well, marginally better than last year, and a little bit better as a group, compared to non-expansion states,” Graham confirms.

Graham says top new trends for payers to pay attention to include consumer engagement, telemedicine, population health, and provider-payer collaborations to support new types of data exchange and alternative reimbursement. Such topics are being discussed in innovative ways compared to how they have been traditionally approached within the healthcare industry, Graham says. Payers that are working with providers and vendors to navigate this change are in better shape to take on new areas of growth. The evidence is in the data, she says.

“The PayerView report measures traditional transactions and workflows that have been tried and true to the industry for years,” Graham states. “Accuracy loss, payment delays, high denial rates, general inefficiency or lack of automation in these traditional metrics signal that the payer may not really be in a great position to take on additional risk or experiment in new areas of growth. That is sort of tangible evidence we can offer the industry in terms of the insight,” she maintains.

Is payer performance enough?

In light of Graham’s insight, payers can positively impact providers in three ways, confirms the payer report card:

  • Payers that return high eligibility accuracy and have strong benefit reliability can more effectively support providers as they collect higher patient obligations
  • Payer and provider collaboration will streamline existing financial, transaction, and administrative workflows
  • Trustworthy payers that breeze through ICD-10 implementation will likely expect seamless future interaction with providers

“Looking back on 2014, a year marked by the implementation of the ACA, we see that payer performance improved overall yet still might not be enough to fully support provider relationships and success amidst continued industry transformation,” states Todd Rothenhaus, Chief Medical Officer at athenahealth.

As healthcare providers become involved in risk-sharing models and navigate through ICD-10 implementation efforts, payers must maintain strong core operations differentiated on performance and transparency to maintain success, so healthcare providers can be efficiently paid, maintains Rothenhaus.