Payers and Providers


Marlowe Dazley

Predicting Denials to Improve the Healthcare Revenue Cycle and Maximize Operating Margins

Healthcare financial leaders are constantly brainstorming ways to increase operating margins through better revenue cycle performance. These efforts often lead revenue cycle leaders to denied claims—when a payer doesn’t reimburse a health system for a service rendered. Although denials are a common reason for lost revenue, experts deem nearly 90 percent avoidable.
Effective denials management starts with prevention. Organizations can use revenue cycle performance data, combined with artificial intelligence, to predict areas within each claim’s lifecycle that are likely to result in a denial. With denial insight, health systems can optimize revenue cycle processes to prevent denials and increase operating margins.

Bobbi Brown, MBA

Today’s Top Five Healthcare Payer Financial Opportunities

Healthcare payers today must develop new business models to address the industry’s mounting challenges around cost, access, and quality. The best emerging models are simple and aligned, accommodate all stakeholders’ needs, and center on the patients/members.
Five key payer opportunities provide a framework for new models that will support the healthcare transformation goals of lower cost, better quality, and increased access:

Understand the impact of the Affordable Care Act.
Be ready for potential shifts due to regulatory impacts.
Understand how social determinants of health impact members.
Focus on provider relations.
Prepare for future trends.

Matt Denison

Healthcare Analytics for Payers: How to Thrive Through Shifting Financial Risk

To stay in sync with healthcare’s transition to value-based care, payers today must develop the analytics capability to support alternative payment models and drive more value to their members. Payers can follow an analytics roadmap to develop a strategy that extends their data, analytics, and risk management expertise to meet growing demands.
The analytics roadmap helps the payer meet these common challenges of establishing a data-driven culture:

Recruiting and retaining high-quality providers in a competitive market.
Managing increasing numbers of high-risk/high-cost members with limited resources.
Efficiently reacting to federal and state legislative and payment changes.
Controlling the rising costs of healthcare services and pharmaceuticals.

Health Catalyst Editors

Customer Journey Analytics: Cracking the Patient Engagement Challenge for Payers

Customer journey analytics uses machine learning and big data to track and analyze when and through what channels customers interact with an organization, with an aim to influence behavior (e.g., buying behaviors among retail customers). Similarly, healthcare organizations want to influence health-related behaviors, such a taking medication as prescribed and not smoking, to improve outcomes and lower the cost of care. In a partnership with an analytics services provider, a payer organization is leveraging customer journey analytics among healthcare consumers to identify the best opportunities and channels for patient outreach. With this analytics-driven engagement strategy, the payer has found an opportunity to significantly improve patient engagement—a predicted overall increase from 18 percent to 31 percent.

Luke Skelley
Matt Denison
Rob McCrory

Six Challenges to Becoming a Data-Driven Payer Organization

As healthcare transitions from fee-for-service to value-based payment, payer organizations are increasingly looking to population health management strategies to help them lower costs. To manage individuals within their populations, payers must become data driven and establish the technical infrastructure to support expanding access to and reliance on data from across the continuum of care.
To fully leverage the breadth and depth of data that an effective health management strategy requires, payers must address six key challenges of becoming data driven:

Data availability.
Data access.
Data aggregation.
Data analysis.
Data adoption.
Data application.

Paul Horstmeier

New Health Plan Shows Commitment to Healthcare Quality

As the healthcare industry continues to transition to value-based models, more health systems are becoming insurers. Intermountain Healthcare’s health plan divisions, SelectHealth, has been around for 30 years. Intermountain has a long history of striving to improve patient care and reduce unnecessary expenses.
Now Intermountain is passing its cost savings onto customers through its new health plan, SelectHealth Share, which locks in yearly rate increases at approximately four percent. There are numerous financial risks associated with this plan, but Intermountain has the systems and infrastructure in place to manage these risks.
The new plan requires close collaboration from all stakeholders: unaffiliated providers must adhere to Intermountain’s changes, like using an EMR; employers must pay at least 70 percent of average premiums; and employees need to proactively manage their health using online tools. Intermountain’s attempts to make coverage a “predictable expense” deserve recognition.

Brian Eliason, MIS
Roopa Foulger

A Guide to Governing Healthcare Claims Data Successfully: Lessons from OSF HealthCare

OSF HealthCare has committed that 75 percent of its primary care patient will be part of a value-based program by 2020. The organization’s leaders knew that success depended on how well they managed their data and decided to build a data warehouse in-house. They recognized that beneficiary claims data was essential to understanding their population better. To get that claims data, however, was no easy task. This required patient matching through master data management and getting buy-in from leaders and physicians throughout the health system. Then, they prioritize where to start efforts using the 80/20 rule and using that as a guide, loaded the claims data.

Bobbi Brown, MBA

Top 7 Healthcare Trends and Challenges from Our Financial Expert

As the healthcare industry moves closer to value-based care, there are a lot of projections about the changes that will occur in the near future. This article discusses seven of the top trends the industry is focused on: (1) physicians start to feel the financial impact of CMS’s rules; (2) the use of technology in healthcare is exploding; (3) financial viability is a key concern for CEOs; (4) reducing exposure to risk performance is becoming more important; (5) interest in population health management continues to grow; (6) outcomes improvements will continue to increase; and (7) collaboration between providers and payers will increase.

Bobbi Brown, MBA
Luke Skelley

The Key to Overcoming the Challenges of Transparency in Healthcare

Transparency in healthcare will drive cost and quality improvements for payers, providers, and patients alike. Consumers want to know true out-of-pocket costs and quality information for their providers. Physicians want to know about their potential referrals partners’ level of quality. In addition, transparency between payers and providers needs to improve to drive down costs. This trend presents challenges such as limited/siloed data access and cultural change. An EDW and analytics system can help transform a health system, improving value and patient/staff satisfaction.

Bobbi Brown, MBA

Healthcare Payers and Providers: The Best System for Process Improvement

Healthcare payers and providers are using new types of financial arrangements to motivate process improvement.

Pay for Performance-a straightforward inventive that rewards improvement based on established metrics.
Bundled Payments-a payer gives a single payment for all provider services, holding providers accountable for reducing waste and eliminating duplication.
Accountable care organization-a total-cost-of-care system that rewards or penalizes based on the total cost of a patient population.

Bobbi Brown, MBA
Luke Skelley

The Best Way to Make Payer and Provider Healthcare Data Accessible

Payers and providers agree that focusing on quality is important. CMS, the HEDIS®, and the Joint Commission all have quality measures hospitals need to consider. Payers have their own set of quality initiatives. Healthcare data is an important part of determining the performance of those quality measures. But complications abound when trying to combine payer and provider healthcare data and measurements. The result is a time-consuming process resulting in reduced ability to analyze the data to drive improvements. Having payer and provider data available would be a huge advantage and is possible through a healthcare enterprise data warehouse. A Late-Binding™ approach provides the flexibility and adaptability needed for quality initiative teams to effect real change within their organization.

Luke Skelley

Accountable Care Means Sharing Data Between Payers and Providers: You’ll Need More than an EHR

Accountable care is changing the way Payers and Providers look at their healthcare data. Many healthcare enterprises believed that their Electronic Health Record (EHR) would be the silver bullet to this data problem, but they are beginning to discover the limitations of the EHR for managing at the enterprise-level all of the information necessary for effective risk-sharing. Health information exchanges (HIEs) help eliminate data silos but are not designed to store or analyze the data with the level of sophistication required for supporting a risk-sharing model. The reality is, until now, providers and payers have lacked consistent incentives to share data.