Revenue cycle leaders agree they need to unite against one common enemy: the payer.
Editor's note: This article appears in the June 2023 edition of HealthLeaders magazine.
Payer compliance was a hot topic for the revenue cycle executives attending the recent HealthLeaders Revenue Cycle Exchange in Carlsbad, CA. Regulatory burdens and never-ending denials are putting massive strains on revenue cycles, and leaders agree they need to unite against one common enemy: the payer.
When it comes to payer compliance, revenue cycle leaders agree there are two major players in the industry that cause the most headaches for them right now: United Healthcare and Blue Cross Blue Shield (BCBS).
According to a poll of the 35 leaders conducted at the event, 44% of attendees chose both United Healthcare and BCBS as the most difficult payers to work with. These results were interesting as other payers came in far behind at 5% for Aetna, 5% for Humana, and 0% for Cigna.
So why these two payers? According to the leaders, United Healthcare and BCBS generally have complicated, multi-tiered structures and rules that seem to always be changing, regardless of their contracts.
Unlike Medicare, which has standard, heavily documented rationales and processes for denials, appeals, and audits, almost anything goes when it comes to commercial payers. Each payer organization will have different rules and processes, and payers’ manuals and bulletins aren’t always easy to locate.
“For us, it's really about new policy changes that they try to impose throughout the year and in the mid-contract period,” Patrick Wall, vice president of revenue cycle at St. Joseph's Candler, said to the group.
Even when policy changes spring up out of seemly nowhere, the leaders agreed that sometimes the administrative burden alone is too much. For example, one change BCBS has made is a substantial increase in the number of medical records it requests to pay a claim.
All this back and forth means that staying compliant with payers has been a burden on their workforce and themselves. With already strained staff it can be hard to find extra hands, and money, to keep up.
“I spent so much time and money in the last four years on legal fees and going through arbitration processes, and I spend a lot of time really holding payers to our contracts. Because we don't have a lot of protections like a lot of health systems, there's a lot of competition in our market,” Wall said.
UnitedHealthcare and BCBS aside, payer relationships are hard to navigate in general, the revenue cycle executives said.
The relationship between a provider and a payer organization rests on proactive communication—like any business relationship does—but what if that relationship seems one sided?
“The house always wins, and that's what the payers are. They hold a lot of the power, and they can take the ball and go home, especially in a city like Atlanta where there's four or five other systems competing for that book of business,” Derek Dudley, AVP of revenue cycle operations at Wellstar Health System, said at the event.
“When either side has too much control, it's hard to have that 'work together' kind of relationship,” Dudley said.
“We're trying though, and we all want to reach out to our payer partners and ask, 'how can we be better partners for you?' In turn, we want them to ask, 'how can we be better partners in working towards that?' But that level of dialogue is sometimes difficult,” Dudley said.
Aside from mending the payer-provider relationship, what else can providers do to strengthen payer compliance? Revenue cycle leaders agreed that having a robust contracting team and frequent joint committee meetings can make a big difference.
“We have a very strong contracting arm within our organization,” Chris Johnson, vice president of revenue cycle management at Atrium Health, said.
Some organizations even have routine have meetings with all of their major payers, such as joint review committee meetings and operating committee meetings, to review issues and organizational impacts.
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Want to hear more about the payer-provider relationship? You are invited to a HealthLeaders Community Call, “Payers Will Be Your Partners or Owners: Get Ready,” on Tuesday, February 28 from 1:00-1:30 pm EST, with Paul Keckley, author of the Keckley Report and one of the industry’s foremost policy and strategy experts. To RSVP, please email Abby Mathis at email@example.com.
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“The house always wins, and that's what the payers are. They hold a lot of the power, and they can take the ball and go home. ”
Derek Dudley, AVP of revenue cycle operations at Wellstar Health System.
Amanda Norris is the Associate Content Manager of Finance, Payer, Revenue Cycle, and Strategy for HealthLeaders.
Revenue cycle leaders have always sparred with payers. It’s so much worse lately.
It's not uncommon for payers to impose new policy changes throughout the year and in the mid-contract period.
The relationship between a provider and a payer organization rests on proactive communication, but what if that relationship seems one sided?