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Tips to staying one step ahead
by Ashley Brown

In the ever-evolving landscape of health care, providers face an ongoing challenge: keeping up with the stringent policies and processes set forth by payers. As payers become increasingly strict and managed care organizations expand their influence, the need for providers to adapt and optimize their operations has never been more pressing. Failure to do so can result in denied claims, wasted resources and ultimately, compromised patient care. To navigate this complex terrain successfully, providers must equip themselves with the necessary tools and strategies to stay one step ahead of payer changes. 

The realm of insurance, particularly managed care payers, has surged in complexity in recent years. With new revisions to policies and an emphasis on meticulous documentation, providers are under immense pressure to ensure clean claim processing. Moreover, the continuous updates of Medicare guidelines have further heightened the need for precision in billing. Failure to adhere to these evolving standards can lead to claim denials, audits, delayed payments and unnecessary administrative work.

The Impact on Providers

For home medical equipment providers, grappling with the intricacies of payer policies poses significant challenges. It necessitates a dedicated allocation of staff, time and resources to keep up with the latest developments and ensure adherence to payer requirements. However, many organizations find themselves stretched thin, lacking the bandwidth necessary to effectively manage these demands. As a result, they risk facing financial repercussions and operational inefficiencies, hindering their ability to deliver optimal patient care.

Considering these challenges—and the need to stay ahead of the curve—proactive measures are essential for providers aiming to successfully navigate the complexities of payer policies. One key strategy involves investing in staff training and development to enhance their understanding of various payers’ requirements and streamline the claims process. By equipping employees with the knowledge and skills needed to navigate payer changes confidently, organizations can mitigate the risk of claim denials and expedite reimbursement processes. Here are some steps to take.

1. Assess your team. 

Begin by evaluating the skills, expertise and interests of your staff members. Identify individuals who demonstrate a keen understanding of payer policies or express a particular interest in mastering this aspect of health care administration. Consider their prior experience, educational background and any relevant certifications or training they may have. Focus on strengths. 

2. Identify specialties or focus areas. 

These specialties within the business processes should align with their skills and interests and could include specific payer claim processing such as Medicare, Medicaid, managed care plans or Blue Cross; customer service; order processing; prior authorization documentation obtainment; denials management or cash posting for example. Product specialties may also make sense for your business. Often each product has its own rules and regulations that add complexity to the process.

 3. Build better processes.  

The next step is implementing robust processes and technologies that can significantly enhance efficiency and accuracy in claims submission and claim management. Leveraging advanced software solutions tailored to the specific needs of health care billing can automate repetitive tasks, minimize errors and ensure compliance with payer guidelines. Insurance configurations and payer tables are fitting examples. Is your software solution set up to know if prior authorization is required? Are there business guidelines for when a phone call needs to be made during insurance and benefit verification? How does your team know what the patient’s estimated total out-of-pocket expense will be? How will the team communicate with that patient to keep them engaged throughout their entire health care journey?  Answering these questions will help you create processes that can set you up for success.  

4. Add analytics. 

Another key is deploying analytics tools to provide valuable insights into claim trends and patterns, enabling providers to identify potential issues early and address them. Start by establishing your company’s baseline key performance indicators (KPIs) and then deepen your understanding by drilling down to understand the areas of improvement within the individual payers and products. This shows where your processes are (or aren’t) supporting your objectives. A great place to start trending data is with your denials. Work to understand what denials are avoidable (i.e., modifier, eligibility, prior authorization) that you are receiving, versus unavoidable denials (mid-month rental or request for medical review).

5. Align expectations.  

Another value of using analytics tools this way is that it helps your team understand expectations and how they are performing. If you define metrics that you expect your team to meet, you need to remain invested in consistently tracking and communicating those results. Consider holding weekly team meetings with participants from cross-functional teams to review results and discuss readiness. If you want to create a thriving and collaborative environment, invest in these meetings consistently. This supports both individual and business goals, which will drive 
your success.  

Strengthen Payer Collaboration 

Effective communication and collaboration are crucial to a successful patient-payer-provider relationship. Establishing clear lines of communication and fostering

collaborative partnerships can facilitate the resolution of disputes and streamline claims processing. Regular dialogue with payer representatives allows providers to stay informed about policy changes, address any concerns promptly and advocate for the needs of their organization and patients.

Furthermore, networking with peers and industry experts can provide valuable insights and best practices for navigating payer challenges effectively. Participating in professional forums, attending conferences, and engaging in knowledge-sharing initiatives available on the payer’s website will broaden providers’ perspectives and equip them with innovative strategies for optimizing revenue cycle management.

The Role of Education

In the ever-evolving landscape of health care payer policies, continuous education is paramount. Providers must prioritize ongoing training and development initiatives to ensure that their staff remain up to date on the latest regulatory requirements and best practices. This may involve investing in continuing education programs, hosting regular training sessions or leveraging online resources and webinars offered by industry associations and regulatory bodies. Rely on payer websites to provide continuous learning material with quizzes and certifications to keep your team up-to-date and compliant.

Fostering a culture of continuous learning encourages staff members to stay proactive and adaptable in the face of change. By nurturing a mindset of continuous improvement, accountability and innovation, providers can position themselves to navigate payer challenges effectively and maintain a competitive edge in the marketplace. The truth is that the revenue cycle management process is complex. Invest in training, quality assurance programs and evaluate data to optimize your revenue cycle team. 

As payers continue to tighten policies and processes, homecare providers must adapt to the evolving landscape to ensure financial sustainability and operational efficiency. By investing in staff training, leveraging technology, fostering collaboration with payers and prioritizing continuous education, providers can position themselves to navigate payer challenges successfully and deliver optimal patient care. 

Also, recognize that you do not have to do all this alone. Consider establishing a relationship with an outsourcing firm to help you navigate these challenges. In doing so, you can mitigate the risk of claim denials, optimize revenue cycle management and enhance the overall financial health and viability of their organizations in an increasingly complex health care ecosystem.

Ashley Brown is senior director of operations for revenue cycle management at Brightree. She  brings more than 15 years of experience, including payer relations and managing staff domestically and globally. In her current role she leads a team of payer analysts, intake specialists and quality assurance specialists who help Brightree customers manage their businesses. Visit