Affordable Care and the Role of the Payer

Why Payers Need to Transition to Affordable Care

Prior to the ACA becoming the law, insurance companies had the authority to deny coverage to patients with previous health problems — insurers work under the pretext that they will be guaranteed regular premiums from customers in exchange for fewer instances of claims payments, which means they are more willing to service a healthy customer than one with a chronic medical condition.

“These changes, although help relieve the patient of mounting medical bills, definitely weigh heavily on the payer……….Payers need to stay afloat and be profitable if they are to woo more customers and facilitate high quality care. To make this happen, insurance companies need to team up with hospitals and the provider networks at large, which is what is happening”

The Act, therefore, was formulated specifically to counter this practice and ensure that patients are not denied coverage or charged more, or worse, offered limited benefits due to suffering ailments at the time of starting a new insurance policy.

Moreover, as per further stipulations laid out in the Act, insurance firms must make room for additional services in their healthcare plans including out-patient treatments, preventive care, as well as wellness medication. These changes, although help relieve the patient of mounting medical bills, definitely weigh heavily on the payer.

**The mandatory tax penalty clause has since been removed, but it does not change the fact that individuals are to be accepted by insurance firms in spite of having prior health problems, regardless of whether or not they opt for Obamacare.

A New Way of Administering Care

Payers need to stay afloat and be profitable if they are to woo more customers and facilitate high quality care. To make this happen, insurance companies need to team up with hospitals and the provider networks at large, which is what is happening.

By having a network of providers in your arsenal under agreed upon contracts, you as an insurer are in a better position to monitor patient journeys and devise policies that are advantageous for you, the providers, as well as the patient in question. You have better visibility into the types and costs of medication being administered to patients due to more transparency in the patient journey, from admission to discharge.

Collaboration with a standard network of providers will help you figure out and provide the kind of offerings in an insurance plan that will most benefit the patient. In essence, insurers like you will be working more closely with providers to determine the best course of action for a patient. This type of integrated healthcare provisioning will also ensure that the team of care specialists within your provider network are delivering the best treatment to patients.

The best part about such joint ventures is that consumers are able to afford non-emergency treatments such as annual health checkups and physiotherapy, giving rise to a system of preventive care. This brings down healthcare costs further as it costs more for emergency care than regular hospital visits.

How to Deliver Affordable Care

The best way to establish a system of coordinated care is to adopt an end-to-end claims management software platform where you can onboard partner hospitals of your choice and communicate with them in real-time. Claims processing software gives you the scalability to reach out to a diverse network of hospitals and other healthcare providers and concurrently formulate a wide array of reimbursement models to suit different consumer segments. Most process automation solutions come with formidable data capture capabilities that will help process the hundreds and thousands of claims documents in a matter of minutes, saving you valuable time and costs on document management. Intelligent process automation (IPA) means the software is embedded with cognitive technologies such as AI and machine learning, enabling end-to-end processing of claims with reduced manual intervention, processing bottlenecks, cycle times, and errors.

Because all claims management is done on a single platform, your communication with providers is more pronounced, consistent, and effective, making for a thoroughly integrated care management solution.

Joint ventures and coordinated care are the way forward and you can take the first step towards partnering with hospitals by setting up an end-to-end claims management system — by doing so, you will not just be joining the bus of integrated care but riding it too!