Leading experts in the Medicare Advantage and Affordable Care Act market continue to call for collaboration between providers and payers. Take an inside-look at their tips to bridge the gap.

Provider/payer collaboration was a consistent theme throughout last month’s virtual conference, RISE National 2020. During the two-day mega-conference, industry leaders shared insights and best practices for providers and payers to remove existing barriers, improve risk and quality, and work together in a virtual world. Here are three of the biggest takeaways.

Break down the barriers between providers and health plans. There are a variety of ways in which a health plan can collaborate with provider partners to limit unnecessary work and burdensome practices as well as develop a more efficient workflow, explained Alan Whittington, director of risk adjustment programs and portfolio management, Highmark, Inc.

Highmark partnered with Arcadia, a health care data and software company, to streamline electronic solutions in place of outdated and burdensome paper processes to simplify access to important information, reduce administrative burdens, and provide curated support.

To gain involvement from providers, Highmark collected and shared extensive data to offer a comprehensive view of the new program, including program capabilities, existing gaps the system can solve, and user group feedback, explained Whittington. “The data told the story so well for us that there wasn’t a whole lot of convincing that needed to happen.”

Highmark transitioned its provider partners to the new technology when the provider felt comfortable, which also allowed the health plan’s support team to deliver thorough provider education, which is key to the process, said Whittington.

The implemented process realigned communication between providers and health plans and provided a clear and searchable user interface, real-time updates and responses, simplified reporting for what’s been done and remains left to do, and monthly reporting for physicians, practice, and the entity to compare performance.

Develop engagement programs to drive quality and risk outcomes. Alignment between payers and care providers can improve risk and quality, as well as member outcomes, said Jeff Dumcum, senior vice president, clinical performance and compliance, Optum, who led a panel discussion to highlight a successful partnership aimed to improve quality and coding accuracy at Optum, UCare, and M Health Fairview.

The payers and providers attributed the collaborative success to four key components: leadership alignment and agreement in partnership, reimbursement realignment from fee-for-service to value-based payment, a thorough operating model, and integrated data systems for a more complete approach to risk adjustment.

The operating model played a critical role in strategy execution, said Jessica Cunningham, R.N., BSN, PHN, director population health strategy, M Health Fairview. The model included:

  • A structured working group with representatives from coding, medical records, population health, quality, and primary care
  • Accountability oversight assigned to Population Health Governance Committee
  • Reprioritization of resources to support providers
  • Regular reporting from Optum IT for data driving and data transparency
  • Weekly status updates with the care system core team and Optum team
  • An end-of-year-gap analysis to develop a sustainable approach through 2020

The updated workflow allowed Optum, UCare, and M Health Fairview to provide their best care while being as accurate as possible. Preliminary results from the collaboration demonstrated a 30 percent improvement rate year-over-year.

Leverage technology as much as possible to collaborate in a virtual world, said Marilee Klock, director coding operations, Geisinger Health Plan. Chart access and retrieval has been a challenge due to the COVID-19 pandemic since most individuals are working remotely, explained Klock. But established, trusting relationships with providers and the use of technology resources such as data feeds has allowed the health plan to continue to receive the same kind of records while maintaining everyone’s health and safety.

Buy-in from the providers is critical to forge these kinds of collaborative relationships, said Rich Bitting, vice president, actuarial informatics, Jefferson Health, who joined Klock for the presentation. “The first thing you have to do is win the heart of providers as far as why this is important,” he said. Communicate a clear value proposition for the patient, provider, and payer to underscore the benefit in collaboration for all parties.

Provider education is an essential component to the partnership, as well. Bitting recommends training programs, tutorial videos, and data-driven feedback to guide providers through the process and make it as seamless as possible. Education has been particularly important since the expansion of telehealth amid the COVID-19 pandemic to ensure providers and health plans fully utilize telehealth and optimize performance. From the provider perspective, noted Bitting, the pandemic is an opportunity to demonstrate the equal, if not better, level of care possible through telehealth.

Because it is new to many providers, accurate auditing, documenting, and coding for telehealth is critical, noted Klock.