Think Tank Insights: Overcoming Payer Tactics

Connex Staff |

Navigating the complexities of healthcare RCM is difficult on the best of days, but that reality is compounded by constant pressure from payers.

Their ever-evolving documentation policies and denial tactics continue to put undue financial strain on Providers, and that trend has been acutely exacerbated year over year since 2020. Connex’s Executive Healthcare Community members met several times in the back half of 2023 to discuss the issue, focusing on the ways automation; analytics; stronger negotiation tactics; and other strategies can help overcome these challenges.

Applying Pressure

  • Achieving transparency will be a critical step to leveling the playing field between payers and Providers. While the former is unlikely to assist in that process, Providers can work collaboratively with one another to help hold payers within their markets accountable.
  • Collective action and lobbying through state hospital associations, insurance boards, and state legislators will likely play a pivotal role in strengthening Providers’ negotiating power over the next few years.
  • Regardless of if the payer relationship is being managed internally or externally, monthly, or quarterly meetings between revenue cycle leaders, negotiators, and payer representatives can go a long way in addressing issues before they exacerbate; creating inroads; and advocacy.
  • That’s doubly true if those meetings are happening face-to-face – physically visiting a payer’s offices, grievances and proof in hand, is particularly effective according to Attendees’ experiences.
  • Preemptively involving inside or outside counsel in those conversations can also be helpful, and will at the very least demonstrate a willingness to litigate if needed.
  • Some have seen success using social media to apply pressure, spotlighting disruptive payer tactics on sites like LinkedIn where they can get visibility and support from colleagues across the industry.

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Equipped with Data

  •  Maintaining detailed minutes of every meeting with payer representatives is key, as it arms legal teams and negotiators with the data they need to demonstrate when and where demands have been ignored.
  • Similar repositories of payer actions, missteps, and issues should be created regularly to inform internal and external teams as they try to address both legitimate and illegitimate denials. Those are strengthened by adding the specific bottom-line impact of each payer decision.
  • Regularly reevaluating charges is a must. Otherwise, Providers risk not having them set high enough and struggling to collect all they should from government payers.
  • Examining, planning for, and directly addressing payer tactics outside of denials are all more important tasks than they were pre- COVID given recent rises in DRG, level of care, and ED downgrades.

Leveraging Emerging Technologies

  • Automation has been particularly helpful in reducing the number of true denials, allowing some to redeploy FTEs to teams specifically dedicated to fighting invalid denials and holding payers accountable.
  • RPA, predictive analytics, and generative AI are all being meaningfully applied to appeal letters, either by guiding staff in how to write them; measuring historic payer trends to better prioritize appeal actions; or identifying which staff members have the greatest appeal success rates.
  • That data can then be used to make better, more integrous decisions upstream, enabling better overall denial prevention strategies.
  • Automation can also enhance appeal letters by automatically pulling and including specific contract language and patient documentation details.

Regardless of the tactics being used to hold payers accountable, negotiate better rates, and garner public sympathy, Attendees highlighted that the optics of the discussion need to be considered. Simply put, focusing on financial hardship and losses, in a vacuum, often fails to get traction. Instead, Connex Members argued that the discussion should be framed from the perspective of patient care and outcomes. How payer tactics directly harm care access and equity; how they lead to delays in authorization and treatment; and how denials and underpayments lead to greater patient financial burdens – which in turn disincentivize care frequency – all make powerful, compelling narratives.