Payer Relationships & The Importance Of In-Network Procedures

  • Healthcare Management
  • case management - medical management
  • July 12, 2022

With the shift to value-based care, strong payer relationships are crucial. Here’s the importance of in-network procedures.

The Shift To Value-Based Care

In recent years, the number of accountable care organizations (ACOs) has reached an all-time high. About 33 million Americans use Medicare, Medicaid, or a commercial ACO. Within these organizations, value-based care models are quickly becoming the norm. This shift from fee-for-service puts a new emphasis on the importance of strong payer-provider relationships and in-network procedures.

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How collaboration is changing

Many providers have already reported that payer-provider relationships are shifting toward more collaboration. This improved relationship leads to better outcomes and higher cost savings. As the shift to value-based care increases, collaboration is more crucial than ever. In the last year, up to 72% of providers said that increasing payer relationships was a priority.

Staying in-network

When an institution or provider is in-network, this means that the payer and provider have already agreed on a negotiated fee schedule. This agreement takes the form of a signed contract that both parties must assess. Institution leaders need to fully understand the terms of this contract to optimize costs and build strong payer relationships.

Reading the fine print

Many carriers are highly specific about what services will be paid for. Hospitals and ASCs should know exactly what these specifications are. For example, many payers will say 110% of Medicare costs are covered but don’t specify which year of Medicare costs. Or, this statement may be accurate for surgical expenses, but ancillary services like x-rays and labs are not reimbursable. Read the fine print and ask all necessary questions before signing a new payer contract.

Improving relationships

Some research has found that open communication is one of the most crucial components of an excellent payer-provider relationship. For value-based care to succeed, providers need to understand what quality metrics are being measured. Additionally, these metrics should hold institutions to a standard of excellence, but also should be realistic and attainable. The key to making sure these goals are achievable is building better payer relationships and partnerships.

Use data

Gathering data is crucial for the value-based care model and for coming up with a payer contract that serves both parties. Many institutions benefit from implementing digital tools or management systems for better data tracking. Additionally, gathering information about social determinants of health is crucial. However, data overload can lead to frustration and paralysis. Make sure to use data strategically, but don’t overwhelm providers with unactionable data or unrealistic goals.

The future of healthcare

Value-based care is the future of healthcare. And with this shift comes an increased need for strong payer-provider relationships. Learn more about improving payer relationships today.

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