Health care payers and providers will need to change the way they work together in the future. A combination of regulatory, consumer and demographic issues will require payers to form tighter relationships with health care providers in order to be successful. And, as with almost any game-changing scenario these days, technology will be at the forefront.

Many issues are driving this imperative. Medicare modernization has generated a constant stream of modifications to how claims are processed, while Medicare consolidation has created fewer but larger geographical jurisdictions for Medicare contractors to serve. Medicare payers must now engage a larger population of providers, yet have the ability to easily and regularly communicate change to the broader audience.

A similar trend exists on the commercial side. Here, Internet technology has been the mechanism for expanding the playing field between payers and providers, by enabling patients to more easily shop around for insurance coverage.

As the health care industry continues to move toward a consumer-driven model, payers and providers need to integrate multiple data sources - across geographic divides - to create a single view of the consumer. Industry adoption of electronic health records is a perfect example of this.

Baby boomers, too, are asserting their presence within the health care system. This group is the largest generational segment in the United States, representing 28% of the total population, with seniors making up the fastest-growing segment for individual health insurance. As baby boomers submit more claims, it can place a huge strain on a payer's existing infrastructure, and lead to decreased cash flow and greater customer dissatisfaction. Furthermore, if President Obama's pre-election health plan to insure all Americans comes to fruition, this would mean potentially millions of additional health care claims.


To remain in the game, payers must develop closer connections with providers. Today, payers tend to have arms-length relationships with providers. Instead, payers should actively explore new methods for making information readily accessible to providers. By providing easier access to claims data, payers can encourage self-service, reducing the number of calls to the help desk, decreasing administrative costs and errors and accelerating claims processing.

On the clinical side, tighter relationships can lead to better patient care and lower health care costs, as the right information gets into the right hands at the right time. Thus, payers will need a more comprehensive, network infrastructure to support increasingly bandwidth-intensive data, built on a secure platform.  

The establishment of a health care provider network is one method payers can use to form stronger links. With it, payers give providers direct access to relevant information, enabling both parties to share data electronically, perform claims transactions online, and provide centralized technical and billing support. A provider network not only saves time and administrative costs by simplifying operations and streamlining communications, it also eliminates the need to process paper claims. In addition, remote workers on either the payer or provider side have the ability to access claims systems online.

A health care provider network is just one example of network technology in action. Payers can use any combination of virtual private networks, managed Internet services, dedicated circuits or wireless to suit their particular needs. The key is making sure that whatever combination is used, it all works together seamlessly in a highly secure and reliable fashion. Payers must also think about who will design and implement the infrastructure, who will manage the infrastructure, and how the company will apportion charges to providers and internal constituencies for use of the infrastructure. Many payers choose to outsource implementation and management of network services to take advantage of the expertise, time-to-market, billing and ongoing management capabilities that a knowledgeable service provider can offer.

The health care industry is clearly at a turning point. Payers that take advantage of opportunities to tightly integrate with providers will be better positioned to grow their business in the future.

Clare DeNicola is president and CEO of IVANS Inc., Stamford, Conn.

(c) 2009 Insurance Networking News and SourceMedia, Inc. All Rights Reserved.

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