Behavioral health practices and payers share the same overall goal: delivering better outcomes while keeping costs low. However, their processes for pursuing this goal are often misaligned, with providers typically focusing more heavily on care delivery and payers commonly focusing on revenue performance and cost control.
Health data shifts the dynamic between payers and providers, enabling more collaborative operations that benefit both sides. The key is understanding data insights and applying them effectively to payer and provider workflows.
This article explores how health data can bridge the gap between payers and providers, ultimately enhancing outcomes for everyone involved.
Reduces Claim Denials
Claim denials make it difficult for providers to be reimbursed for their services. In addition to straining operational and financial resources, denied claims also consume valuable time and effort because they tend to involve unnecessary back-and-forth between teams.
Health data offers transparency around services provided, helping payers validate claims and helping providers get paid faster. Below are a few common reasons for claim denials and ways that health data can prevent them:
- Incomplete or inaccurate records: Comprehensive and up-to-date health information ensures claims contain the essential information needed to validate the services provided. Health data platforms integrate information from various sources, such as electronic health records (EHRs) and physician notes, to create complete and accurate patient profiles.
- Medical necessity disputes: Data-driven insights surrounding diagnoses and treatment plans provide the critical evidence needed to support a service’s medical necessity. The ability for providers to share data with payers enables informed decisions and alignment on care delivery that supports improved patient outcomes.
- Duplicate billing: Lack of coordination can cause administrative errors, such as duplicate billing, which can quickly become confusing and result in denials. Providers and payers can remedy this by enhancing health data exchange and monitoring claims data. Improved visibility supported by data exchange also helps payers and providers avoid duplicative or unnecessary services.
A health data platform presents the solution to many of these challenges. This software gathers and enriches all important patient data to convert it into a usable format. The platform then stores the information in a data warehouse and applies features like dashboard reporting, integrations, and other applications to derive insights.
Surfaces Performance Insights
Arcadia’s guide to performance improvement in healthcare explains that balancing care quality and cost management is a major priority that necessitates a standardized approach to assessing operational performance. Health data plays a critical role in this process, enabling providers to deliver comprehensive care and payers to eliminate inefficiencies.
More specifically, health data can provide insights into:
- Patient outcomes: Evaluating treatment effectiveness, readmission rates, and other health data allows providers to identify best practices and refine their approaches to improve patient outcomes. For payers, this information reveals the value and quality of different services and interventions.
- Service utilization: Emergency room visits, specialist consultations, and other service utilization records show how often patients used certain services and what effect those services had on their health. With this context, payers and providers can identify patterns that allow for better resource allocation and reduce unnecessary costs.
- Population-level trends: Aggregated health data reveal patterns within the larger population, surfacing prevalent diseases, health disparities, and other emerging trends. Evaluating data at this scale enables providers and payers to collaborate on public health interventions, targeting health programs, and other initiatives addressing a community’s needs.
Beyond current performance, these insights are also vital for intelligently scaling services based on data-backed insights into current successes and opportunities to allocate resources more effectively. Health data platforms automate the analytics process, making it easy to continuously monitor key metrics and promptly flag improvement opportunities.
Enhances Collaboration
Consider a patient with a cardiovascular condition. When treating this patient, providers might focus on clinical data like blood pressure trends and medication adherence to decide what interventions would be best for their health. Payers, on the other hand, may only see fragmented claims data showing multiple emergency room visits and rising costs. In this scenario, payers lack the context to understand why those visits were necessary and how providers can optimize care delivery so that a patient receives the right care in the right setting at the right time.
Health data offers a strong foundation for payer-provider collaboration. When both parties operate from the same base of aggregated health data, their collaboration will naturally become more effective. Additionally, data-driven alignment leads to:
- Increased transparency and accountability: A mutual understanding of performance against agreed-upon metrics supports greater trust between payers and providers, ensuring everyone is working toward the same objectives.
- Provider input into negotiations: Clear visibility into operational performance allows providers to articulate the value of certain services and advocate for better contract terms with payers.
- Improved contract terms: Over time, data alignment demonstrates reliability, which can potentially lead to more favorable contract terms and incentives.
Ultimately, objective data and ongoing communication foster a sense of partnership between payers and providers, encouraging both parties to become invested in the other’s success. After all, payers and providers share the same goal: supporting the overall health of the patient population.
Bonus: How to Operationalize Health Data
While health data has the power to bridge payer-provider gaps, this information is only effective when it’s fully operational. Here are some tips for ensuring your data is ready to use:
- Invest in analytics software that streamlines healthcare data aggregation, sharing, and analysis.
- Align providers’ key performance indicators (KPIs) with common payer metrics to track progress toward shared goals.
- Regularly benchmark performance and automate reporting to ensure alignment on current progress and priorities.
While data-driven insights are likely already an intrinsic part of providers’ care delivery workflows, using health data to evaluate and report on performance is critical to bridging the payer-provider gap. Recognizing the power of health data is only useful when health organizations follow responsible best practices for sharing and acting upon data-driven insights.
Final Thoughts
The future of behavioral health is collaborative, and health data lays the groundwork for this dynamic. For payers and providers, this means sharing data and insights to remain committed to shared goals. As a result, your entire health system will build a stronger foundation for sustainable, outcomes-driven care.
