Navigating the Complex Landscape of Payer Policy Changes

by Kacie Geretz, RHIA, CPMA, CPC, CCA

Healthcare is rapidly evolving due to rising costs, advancements in medical technology, and new policies and guidelines. This dynamic environment forces payers to frequently update their policies on reimbursement rates, coverage criteria, billing, and prior authorization requirements. However, the lack of standardized guidelines for these updates poses significant challenges for healthcare providers.

The Challenge of Payer Policy Changes

Each payer operates independently, leading to diverse and inconsistent rules. These updates are not published in standard formats or timelines, making it difficult for providers to stay informed. Traditional manual systems for keeping up with changes are inefficient and unreliable, putting providers at risk of compliance issues, denials, and lost revenue.

Drivers of Payer Policy Changes

1. Rising Healthcare Costs: Inflation, higher pharmaceutical prices, and labor shortages force payers to adjust policies to balance coverage and affordability.
2. Advancements in Medical Technology: New treatments require payers to evaluate their cost-effectiveness, leading to changes in reimbursement and coverage criteria.
3. Government Regulations: New laws and updates to existing regulations necessitate adjustments in payer policies to ensure compliance.
   

These factors compel payers to update their policies frequently, creating challenges for providers whose revenue depends on compliance.

 

Challenges for Providers

The increasing frequency and complexity of policy changes create significant hurdles for providers:

• Inconsistent Rules: Over 1,000 different payers have unique policies, making consistency a major issue.
• Complex, Lengthy Changes: Payer guidelines are often intricate, making it difficult to identify relevant updates.
• Limited Communication: Providers must manually monitor payer websites and newsletters, a time-consuming and error-prone process.

 

Best Practices for Managing Policy Changes

 

Automate Payer Policy Alerts

 

Software solutions can scan payer websites and newsletters, consolidating updates into frequent reports. Automation ensures no changes are missed, helping providers stay compliant and avoid revenue loss.

 

Automate Edits Within Billing Workflows

 

Automating the detection and implementation of policy changes within billing workflows minimizes denials, underpayments, and compliance risks by proactively identifying affected claims.

 

Automate Coding
Automated coding solutions use artificial intelligence to assign medical codes and include the latest payer policy changes, ensuring compliance and reducing the need for retrospective edits.

Getting Started with Automation

Providers should invest in processes and technology to improve payer policy management efficiency. Identifying the stages of the revenue cycle with the most denials and underpayments will help select the most impactful solutions.

 

Staying updated with payer policy changes is crucial for compliance and revenue optimization. Automation technology can help providers manage these changes proactively, reduce administrative burdens, and minimize the risk of denials and underpayments. Investing in these solutions is essential for navigating the complexities of modern healthcare.

 

 

This OHIMA Blog article is a summary of an article published on For The Record.
Garetz, K. The Complexity of Payer Policy Changes. For The Record. https://www.fortherecordmag.com/archives/Fall23p26.shtml. Published Fall 2023. Vol. 35 No. 4 P. 26 

 

Additional References
1. Norris A. Rev cycle leaders call out two major players in their fight with payers. HealthLeaders Media website. www.healthleadersmedia.com/revenue-cycle/rev-cycle-leaders-call-out-two-major-players-their-fight-payers. Published February 24, 2023. Accessed August 30, 2023.

2. Cass A. Biggest challenges facing revenue cycle leaders. Becker’s Hospital Review website. www.beckershospitalreview.com/finance/biggest-challenges-facing-revenue-cycle-leaders.html. Published June 8, 2022. Accessed August 30, 2023.

3. Lagasse J. Payers could see 7% spike in healthcare costs in 2024. Healthcare Finance News website. www.healthcarefinancenews.com/news/payers-could-see-7-spike-healthcare-costs-2024. Published July 5, 2023. Accessed August 30, 2023.

4. How to keep up with changing payer requirements. Experian Health website. www.experian.com/blogs/healthcare/2022/05/how-to-keep-up-with-changing-payer-requirements/. Published May 25, 2022. Accessed August 30, 2023.

5. National Association of Insurance Commissioners. U.S. health insurance industry analysis report. https://content.naic.org/sites/default/files/inline-files/health-2022-mid-year-industry-report.pdf. Published 2023. Accessed August 30, 2023.

 

About the Author 

Kacie Geretz, RHIA, CPMA, CPC, CCA, is the revenue cycle management solutions manager at Nym (www.nym.health), a health care technology company that leverages artificial intelligence and clinical language understanding to fully automate the medical coding process. As a key member of Nym’s commercial team, Geretz focuses on aligning Nym’s product roadmap to the needs of the company’s customers and ensures that Nym’s medical coding engine is always compliant with the latest regulatory updates. Prior to working at Nym, she managed mid to backend processes such as revenue integrity, chargemaster, managed care contracting and credentialing, and denials analytics within health systems and medical centers.