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It’s Time for Payors to Scale Intelligent Automation to Improve Interactions with Providers

Joel Krishnan

Senior Manager, Intelligent Automation Consulting

Michael Capofari

Manager, Healthcare Consulting
Blog
  • Healthcare

As the global pandemic continues to significantly alter the healthcare landscape, the goal for both payors and providers has remained steadfast: provide the best possible experience for patients and members in an effort to continuously drive better health outcomes. Despite this mutual goal however, the relationship between a payor and its provider network is often overlooked and is currently fractured due to the many manual and redundant steps needed to truly complete the end-to-end care delivery journey.

COVID-19 has further highlighted the importance of the payor-provider relationship with disrupted value-based care pay-for-performance models, retroactive disenrollment among patients and evolving financial relief solutions. It is more essential than ever before that payors and providers find ways to work together effectively and efficiently. To do this, payors should consider how intelligent automation can diminish or eradicate pain points within this relationship to ultimately improve the healthcare journey for patients.

Administrative Costs

In a multi-payor system, administration costs and effort are among the top reasons for provider staff burnout due to increased cost drivers and system-wide reforms. Providers, contractually obligated to acquire pre-authorizations from payors for certain procedures, are finding even longer wait times than usual to contact payors as telephone traffic continues to spike due to COVID-19. In a recent study, 86% of physicians say prior authorization remains a significant burden, while payors are increasingly using prior authorizations to lower costs by minimizing duplicate care. Automating prior authorization steps, like digitalizing authorization forms, validation, routing and information-gathering for easier decision-making, would help alleviate these challenges and speed up the revenue cycle.

Additionally, payors should consider implementing a modern approach to improving provider data quality to eliminate challenges with administrative costs. This could mean periodically auditing and maintaining the data across disparate systems, enabling a virtual assistant to answer provider queries as a self-service option rather than reaching out to the provider call center, digitizing provider onboarding or periodically checking for adequacy requirements via network assessments. These tactics would go a long way in alleviating provider dissatisfaction and avoiding possible fines from CMS or ACA. 

Healthcare BPO Services

All large payors outsource portions of their non-core activities to offshore BPO centers for better operational benefits. While this helps in net revenue, COVID-19 has exposed the BPO industry with inadequate infrastructure, data security concerns and productivity losses. This has opened the door for payors to re-examine their large-scale outsourcing contracts while trying to improve operational efficiency through automation as much of the outsourced work consists of mundane, repetitive tasks. It is an excellent opportunity to take the work back-in house and find ways to automate, thus enabling faster response to providers. Some examples of quick-win automation opportunities include:

Financial Burden

Millions of people have lost their health insurance in the pandemic-driven recession. At the same time, payors and providers are facing unprecedented financial pressure due to COVID-19, which has resulted in providers reducing their staff and cancelling non-emergency, elective procedures. Estimates show that the healthcare system lost $50.7 billion per month over a four-month period from March 1, 2020 to June 30, 2020. While payors are continuing to see a spike in claims due to the ongoing pandemic, coupled with the fact that few insurers anticipate raising 2021 premiums, the emphasis on payors to manage their bottom line has never been greater. This situation pushes players across the healthcare industry, especially payors, to reduce operational spending and look for opportunities for efficiency gains. Automation is no longer considered as an investment but a necessity to deal with the cost pressures. Payors must scale up automation across their operations to increase efficiency and supplement their workforce. 

Delay in Strategic Investment Across Payors

According to a recent survey about how COVID-19 has impacted IT spending, nearly 60% of midsize and large companies have paused deployments of new technology not currently in their IT stack, 54% have delayed upgrading existing hardware, and 44% have delayed feature add-ons or upgrades to existing software. We are seeing similar trends among the healthcare industry. Strategic initiatives around provider data management, provider lifecycle management and provider call center automation may be pushed or delayed. But the current market landscape provides an opportunity for robotic process automation (RPA) to get quick wins with comparatively small investments. With RPA acting as a bridge technology to future larger scale intelligent automation solutions, payors can mobilize and stand up teams quickly to achieve greater efficiency in payor-provider operations with relatively less budget when looking for interim solutions.

Conclusion

Now, more so than ever, it’s imperative that both payors and providers do everything they can to support their members and enhance the patient experience in this unprecedented time in history. As the healthcare industry continues to navigate market changes, the relationships between payors and their provider network will continue to be tested. It’s the right time for everyone in the healthcare ecosystem, especially payors, to lean on technology to automate the handoffs between them to not only make their lives easier but ultimately improve the patient experience as well.

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