More on Reimbursement

Preventing Physician Abrasion Related to Claims Payment

Although physicians have always valued prompt, accurate and complete claims payment, the need for such payment has become more important as physician practices try to balance increasing costs with shrinking reimbursement.

Because of narrowing margins, it can be very frustrating to physicians when claims payments are delayed or rejected, particularly when there is no immediately identifiable cause. Also, when a physician has to regularly fight to receive full reimbursement, it can put a strain on the provider-payer relationship.

If left unchecked, physician frustration due to poor claims payment can escalate, leading to mistrust, suspicion and even hostility. Ultimately, it can wear on provider-payer interactions, causing physician abrasion – where a payer's relationship with a physician is negatively, and sometimes irrevocably, impacted by certain activities or circumstances.

One consequence of physician abrasion is member abrasion. This is where health plan members are negatively influenced by physician frustration. For example, if the physician is irritated with the payer for delayed or incomplete payments, he or she may inadvertently communicate that frustration to the patient, giving the impression that the payer does not care for the patient's healthcare needs. In addition, a physician may seek payment from the patient if a claim is denied or only partially paid, which can reflect poorly on the payer.
Over time, physician abrasion can be toxic, causing long-term adverse effects for payers, including physician attrition, member attrition and lost revenue.  

Strategies for Overcoming Physician Abrasion
The good news is that physician abrasion is preventable. The following are a few strategies to consider, which cannot only enhance your relationship with physicians, but improve your health plan's performance long term.

Define payment processes and consistently follow them.
The more transparent a health plan is about their claims adjudication and payment processes, the better. Clearly defined processes that are consistently followed can foster physician confidence. Conversely, lack of information and inconsistency can breed physician mistrust because physicians may get the impression the health plan is trying to hide something.

Well-defined processes should set clear expectations regarding claim submission, timing of adjudication, remittance procedures, appeal processes and so on.

Spending time designing payment processes to enhance efficiency, accuracy and workflow has the added benefit of helping your health plan improve its own performance while reducing costs. In other words, it's a win-win for both preventing physician abrasion and improving business performance.

Automate claims adjudication where possible.
Leveraging technology to streamline the adjudication process can improve efficiency as well as consistency. This allows claims payment to be more timely and predictable, something physicians appreciate. Automating the adjudication process can also benefit your health plan because software or Web-based adjudication tools are more cost effective than manual approaches. Adjudicating claims manually requires significant staff resources and time, which can slow the adjudication effort and also add a human element to the process--introducing the possibility of error.

Ensure consistency when claims do not process automatically.
Not every claim will pass smoothly through the automated adjudication tool. When claims kick out of the system, payers should have a consistent process in place to address them. If your approach is haphazard, it may cause confusion and further frustration.

If a physician reaches out to your health plan with questions about a claim, you should be able to answer those questions promptly, giving specific reasons for a delay in payment, items needed to get the claim moving again and timelines for resolution. Even though the physician may be irritated that the claim is delayed, you can temper that frustration if you clearly communicate the steps and timeframes involved in resolving the issue.

Regularly review denied claims.
While claims adjudication is typically a reactive process, those payers that take a more proactive approach benefit in terms of encouraging better relationships with physicians. Such an approach may involve regularly reviewing the types of claims being denied to see if any patterns emerge. The payer can then reach out to the provider and offer suggestions to avoid these kinds of denials in the future. Taking the initiative to identify and work with physicians to resolve potential issues demonstrates your willingness to partner and streamline claims payment.

Clarity and Consistency are Key
Fundamentally, payers that want to support continuous physician goodwill should clearly describe their claims payment processes and enforce them consistently so there is no confusion on how and when a claim will get paid. As much as possible, payments should occur quickly and without delay. By taking these steps, you can lay the groundwork for strong provider-payer relationships while improving your own business performance.

Rolland is the senior vice president, product development for Medicare Advantage at Outcomes Health Information Solutions.
This article is the third in a series about physician abrasion. Over the course of the series articles, we will delve into descriptions of different types of physician abrasion and outline the impacts on payers and providing tips for avoidance.