Top 5 Payor Trends Impacting Reimbursement

Recent regulatory updates and payor policy changes could have a big impact on providers’ operations and bottom line. Ensemble’s experts break down the top five macro-trends you and your organization need to know about now to avoid underpayments, denials, and impacts on patient volume.

Trend #1: Payors becoming providers

The line between payor and provider is becoming more blurred as payors continue growing their presence in primary care, post-acute care, telemedicine, behavioral health, pharmacy and other care delivery environments. Optum has become one of the country’s largest collections of doctors, with more than 5% of physicians in the United States. Earlier this year, Cigna agreed to buy MDLive in an expansion of its telehealth offering and Humana acquired a South Florida primary care physician network.

Trend #2: Rapid-fire policy updates and regulatory change

So far in 2021 alone, Ensemble has tracked and documented more than 46,100 payor updates. Recent significant updates included:

These policies updates and regulatory changes are constant, sometimes seemingly arbitrary, and sometimes lacking in guidance or specificity for how to implement or comply.

Policy were relaxed during the lowest volume of COVID cases, but reinstated during the peak. Relief provided was temporary and has not provided the support health systems have needed throughout this pandemic.

Trend #3: Increasing investment in mergers and acquisitions, payment integrity technology

Payor investment in fraud detection and payment integrity solutions is estimated to increase by 30% by 2025. Payors are focusing on acquisition and building in-house strategies in an attempt to reduce the nearly $170B spent on inaccurate claims and payments annually. Anthem handles roughly 85% of payment integrity related activities in house and partners with dozens of outside vendors to cover the remainder. Optum has acquired Equian and Change Healthcare and estimates $326 billion in cost savings via enhanced capabilities.[1]

Core payment integrity solutions payors are leveraging:

  • Claims editing: Variety of capabilities from simple rules to complex algorithms
  • Clinical validation: Typically, clinical coding teams to ensure diagnoses are substantiated
  • Inpatient claims review: Systematic review and evaluation of provider claims
  • Fraud, waste, abuse: Predictive analytics are increasingly common
  • Subrogation: Injury claims are increasingly picked up on the front end through specific rules

Trend #4: Payor policy conflicts with clinical guidelines

  • National coding guideline conflicts – for example, application of Sepsis-3 criteria to claims is illegal in California and New York yet CMS still utilizes Sepsis-1, which can create conflicts with review of their claims for Massachusetts plans
  • Downgrading ER visits based on final diagnosis, not presenting diagnosis
  • Accessing lab data for downgrades 

Trend #5: Payor redirection of care

Payors have recently issued a number of policies aimed at redirecting patient care with the goal of steering patients to treatment outside of hospital settings. In their attempts to do so, payors are disregarding pre-existing contracts with providers and complicating the patient experience and pre-authorization processes. These policies make it increasingly more difficult for providers to deliver exceptional patient experiences without a negative impact on their bottom line. For example, UnitedHealth Group (UHG) recently published an article aimed at plans, members, and their caregivers encouraging “non-complex commercially insured individuals” with employer coverage to seek treatment for common outpatient procedures in Ambulatory Surgery Centers (ASCs) versus a hospital setting.

Tips for combatting payor pressure

  • Know what you’re up against
    • Have a strategy to cut through the noise of the thousands of updates to get the ones with the most impact
    • Identify in-house or partner SMEs who can stay on top of changing regulations
    • Understand contractual implications
  • Leverage volume to your advantage
    • Submit aggregated disputes that reflect the impact of payor policies
    • Engage state government where necessary
    • Submit bulk sampling to government agencies in complaints to show the volume of patient care impacted
  • Be an active advocate
    • Take advantage of engaging in notice and comment periods for regulatory change
    • Engage with state legislatures and administrative entities to push back on payor policies

Concerned about navigating this complexity on your own? You don’t have to.

At Ensemble Health Partners, we help providers manage complex payor regulations and adapt to evolving trends by empowering them with the data and operational expertise they need to remain compliant, avoid lost revenue, and continue to deliver on their missions of providing quality care to their communities.

Tap into the power of over 7,100 certified healthcare revenue cycle experts today by emailing [email protected].

[1] Guggenheim Securities, Provider-Payor Trends Report April 2021