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Process Automation Ensures Care for All

March 24, 2020

Affordable Care and the Role of the Payer

Going it alone is passé. Joint ventures are all the rage as insurers increasingly witness the benefits of teaming up with healthcare providers. And a robust claims processing software is helping them achieve this.

A lot of good happens when two entities collaborate to service the customer better. A great deal of good happens when insurers and providers team up to facilitate affordable care. This has been the trend for the past few years and continues to gain momentum as collaborators see the combined benefits of offering patients the best care at affordable prices. Joint ventures between hospitals and insurance companies is the norm today—the more skilled provider networks teaming up with the more reliable payers, all for the benefit of the patients. This new model of healthcare delivery is called integrated care.

This latest trend in medical provisioning is a gradual aftereffect of the policies and proposals that were formulated in the Affordable Care Act (ACA). The ACA or Obamacare, as it is commonly known, came into effect as a result of the then government’s efforts to reduce the costs of healthcare. The Act stipulated that everyone must buy some form of insurance or face tax penalties.**

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.

Removal of this non-compliance clause has proven to be very costly for payers as they now need to compulsorily admit patients suffering chronic or pre-existing conditions, which means more claims payments and lower premium rates. A recent study conducted by FinTech Futures revealed that one of the top challenges faced by the insurance industry in 2019 was market risk, suggesting a lack of profits and consistent cost constraints as a result of low rates and subsidies for low income families—both factors are provisions under the ACA.

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!

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