Gartner Research

Healthcare Payer CIOs, Look in the Mirror to Improve Payment Integrity

Published: 05 September 2018

ID: G00366635

Analyst(s): Mandi Bishop

Summary

Disjointed payer business processes, incomplete information and legacy system limitations cause payment integrity problems that undermine both payers’ and providers’ operational efficiency and financial performance. U.S. healthcare payer CIOs must attack root causes to improve payment integrity.

Table Of Contents

Analysis

  • Payment Integrity Improvement Starts With Payers
    • Payers Must Tackle Payment Integrity Problems to Regain Provider Trust, Maintain Competitive Networks and Optimize Savings
  • Acknowledge the Provider Truths That Affect Payment Integrity
    • Clerical Work Consumes 70% of Physicians’ Time
    • Clinicians Do Not Have Clear Visibility Into Payer Contract Terms
    • Clinicians Do Not Control Coding and Billing
    • Providers Cannot Submit Clean Claims If Payer Policies Are Ambiguous
  • Make Payment-Related Information Actionable for Providers
    • Communicate Payment Policy as Business Rules
    • Revamp Provider Network Management Systems
    • Prevent “Unacceptable Exceptions” From Proliferating
    • Ensure Member Eligibility Information Is Accurate and Available in Real Time
    • Communicate Claims Edits as Business Rules
    • Communicate Medical Policy as Business Rules
  • Set Hard Savings and Provider Alignment Goals for Payment Integrity
    • Baseline Current Financial Performance of Payment Integrity Initiatives
    • Baseline Current Provider Alignment
    • Establish Specific, Measurable Improvement Targets

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