What Payviders Need to Know About Maximizing Reimbursement

Industry experts believe that the number of payvider organizations will grow as more healthcare organizations look to diversify payment models and expand patient-centric capabilities. The value-based care model carries increased risks and benefits, and insurers and providers joining forces to increase the quality of care and minimize their financial risk can be a beneficial outcome for all parties involved. As the industry continues to evolve and organizations adapt, how will this organizational trend move the needle toward a more efficiently effectively managed revenue cycle?

Under value-based care, there has been a visible increase in traditional organizations making the move to a more all-encompassing operational model. Mergers and acquisitions, plus market expansion, have led to the emergence of additional payviders in recent years, and the trend is set to continue. More than half of health system CFOs surveyed by the Healthcare Financial Management Association mentioned plans to enter risk-based payment models in 2022.

So what exactly is a payvider? Merging the roles of a traditional payer and provider services, payviders share the duties of managing member care. Supporters believe the model can reap benefits for providers, payers and patients. Efficiencies are created, and reduced financial risk, improved quality of care and increased profitability are the ideal outcomes. Of the three payvider models, healthcare providers creating their own insurance plans is the most common version, with over 300+ health systems currently in the United States. Prominent names like Kaiser Permanente fall under this category. Joint ventures, such as the one between Aetna and Banner Health, are also gaining popularity. Lastly, an established insurance company can opt to shift to offering healthcare services, like Humana.

The idea behind the model is that payviders are able to deliver cost-effective healthcare. When payers and providers collaborate to meet their respective goals, cost savings benefits all. Additionally, with a value-based care model, improved health outcomes and better patient experiences can also be realized. When the value-based care model’s focus centers on quality over quantity, providers (and ultimately, the payvider organization) are rewarded for efforts that promote overall wellness, differing from the traditional fee-for-service approach. When healthier lifestyles are promoted by healthcare professionals – through education, preventative measures, patient behavior and tools like telehealth and in-home monitors – better outcomes arise. An overall healthier population means a reduction in chronic diseases, better mental health, less critical care instances and reduced hospital stays.

The value-based care model, whether a payvider organization or a traditional payer and provider contract, carries risks and benefits. Patients must take a more active role in their healthcare with the prompts given from their providers. Data collection is even more important to monitor progress within a patient population. Patient-centric data across multiple types of care is required to correctly determine if value-based care’s financial goals and outcomes are being met. For providers, more financial risk is passed on from the payer – which must be carefully monitored so not to cause revenue leakage. It is critical that providers are paid correctly and reimbursement is accurately tracked. Tools like Advanced Reimbursement Manager (ARM) from TriZetto Provider Solutions makes data collection, contract compliance audits and appeals processing easy and efficient. ARM simplifies root cause analysis of both payer reimbursement issues and denied claims, giving providers a roadmap for revenue maximization. This allows more time to focus on patient episode outcome and reach those value-based reimbursement goals.

As more healthcare organizations look to diversify payment models and expand patient-centric capabilities in the future, many industry experts believe that the number of payviders will continue to grow. With value-based care well established, we will see more insurers and providers joining forces to increase the quality of care and minimize their financial risk. With this, the industry continues to evolve, and organizations need to adapt. While there may be more financial risk by joining forces, payviders can also reap higher rewards in the form of cost savings and profitability if they are able to efficiently and effectively manage their complicated revenue cycle. The bottom line is that right steps need to be taken to realize higher cost savings, and a large part of that is having the right services and solutions in place to support the revenue cycle. Using ARM as your data engine also allows users to monitor metrics to research, track and analyze data. With full visibility into reimbursement trends, payviders will have the ability to make more informed business decisions that will benefit all parts of the organization, keeping the patient at the center of the operating model.

Looking to ensure money earned is properly collected? Discover Advanced Reimbursement Manager from TriZetto Provider Solutions today. Click here to learn more.