As our industry continues to delve deeper into streamlining and improving complex healthcare payments processes, healthcare payers are recognizing the increasing necessity to adopt new innovative methods to uphold and improve their payment integrity programs. The stakes are crucial – the U.S. spends twice as much on healthcare compared to similar countries, with administrative costs more than three times higher.
Stopping unnecessary costs before they start requires transforming the way payers help providers to recognize medical billing and coding errors so they can proactively monitor performance and self-correct as quickly as possible. Traditional tools are no longer sufficient – they lack the transparency and automation that payers and providers need to spot opportunities for early intervention, leading to time-consuming medical claim reviews and delayed or denied payments that stoke provider abrasion.
With a growing emphasis on real-time insights, proactive measures, and payer-provider collaboration, the next generation of AI-driven provider education solutions emerge as essential in lowering pre-claim submission costs and achieving greater healthcare payment accuracy.
The Biggest Gaps in Provider Education Today
Where do current provider education tools and processes fall short, particularly with empowering providers to take quick and proactive self-corrective actions that improve payment integrity?
Key pain points include:
- Inadequate Real-Time Insight on Billing and Coding Performance: Many traditional provider education tools lack the ability to provide real-time insights for timely issue resolution for billing and coding errors. Both providers and payment integrity teams face challenges with delayed data, which hampers their ability to address issues promptly.
- Lack of Peer Insight: Providers often lack visibility into how their performance compares to their peers, missing early signs and opportunities to rectify common mistakes and align with industry best practices.
- Reactive Efforts Drive Abrasion: Historically, the healthcare industry has relied on reactive measures to address medical claim coding errors, including identifying coding and payment issues post payment. This approach causes friction between payers and providers.
- Educational and Support Challenges: Accurate provider billing and coding require ongoing education and accessible support. However, many existing tools do not provide adequate resources to keep providers updated and well-supported, leading to gaps in knowledge and practice.
A Provider Portal is Essential For Next-Gen Provider Education
As healthcare organizations enhance their provider education programs, we recommend they seek tools with sophisticated AI-driven capabilities and a provider portal that will deliver:
- Self-Service Capabilities for Transparency: Innovative provider education portals – such as Codoxo’s Provider Scope – foster self-reliance for current performance. Provider Scope proactively identifies provider coding and billing issues and transparently shares trends and insights to providers via the portal for review and self-correction.
- Provider Peer Benchmarking: With self-service portal access, providers gain new visibility into how they perform relative to their peers. Comparative dashboards and side-by-side charts illustrate specific coding behaviors driving up costs compared to others like them based on multiple dimensions.
- Real-time Insights on Coding & Billing Performance: AI-based provider education tools improve coding accuracy with pre-claim insights and interventions that allow payers to address non-compliant behavior earlier in the payment cycle.
- Automated and Proactive Auditing: Automated process workflows enable payers to proactively address concerns before they result in financial loss or compliance issues. This also reduces administrative burden on providers, allowing them to focus on delivering quality care rather than managing post-claim corrections.
- Monitoring, Alerts and Communications: A shared digital portal for providers and payers enhances collaboration, streamlines communication, and enables simplified sharing of coding best practices and guidance. Payers are now able to serve as a trusted resource for providers by offering training, education, and accurate performance reporting that will help them self-correct and avoid downstream reactive measures.
The Future of Healthcare Payment Integrity
Acknowledging the hundreds of billions of dollars from improper claims payments and fraud that continue to plague the U.S. healthcare system, a recent report from analyst firm Gartner urged healthcare payers to integrate proactive payment integrity to prevent erroneous payments before they are made.
We’re in an era of healthcare transformation, and a new generation of AI tools are demonstrating tangible outcomes: enhanced payment accuracy, greater compliance, and reduced financial waste through improved coding practices.
These proactive features enable the early detection of discrepancies, reduce the burden of audits and corrections, and foster a more collaborative and trusting relationship between payers and providers. Even beyond these benefits, the strategic approach of enabling provider self-audit promises a more sustainable and effective healthcare ecosystem, underscored by self-service, transparency, and peer-to-peer visibility.
Help fix the U.S. healthcare cost problem. Learn more about Codoxo’s Provider Scope today. Contact us at info@codoxo.com.
