Blending Human Expertise & Technology to Improve Claims Negotiations

November 13, 2023 - Out-of-network claims remain a challenge for a healthcare system looking to improve utilization and spending of services. For health plans, negotiating fair prices for out-of-network services is integral to avoiding provider abrasion and out-of-pocket costs for members, many of whom are now enrolled in employer-sponsored high-deductible plans. Partnering with a strategic team that combines negotiation expertise, clinical insight, and coding proficiency can enhance the management of out-of-network reimbursement, both pre- and post-payment, ensuring efficient operations and preserving relationships.

A 2018 analysis of out-of-network claims at large employer health plans found that roughly 18% of hospital stays and 7.7% of outpatient visits had at least one bill from a provider outside the plan’s network, with the percentage rising to 9.2% when the visit involves facilities like emergency rooms or outpatient hospitals. While the No Surprises Act has introduced measures to prevent surprise billing and resolve claim disputes between providers and payers, its implementation has been hindered by technical and legal challenges, and it still represents a last-ditch effort fraught with creating animus between stakeholders.

It is therefore unsurprising that forward-thinking health plans are placing sizeable emphasis on more productive and efficient claims negotiation approaches that can reduce costs and avoid the need for similar negotiations moving forward once relationships between payers and providers are established and trust builds.

According to Zelis Vice President of Negotiations and Claims Management Michael Chang, payers must place a high value on strategic claims negotiations and the role of human and artificial technology in enhancing the processes around out-of-network claims.

“To make negotiators as productive and effective as possible, technology should be employed selectively,” he explains. “The process to identify where technology is needed involves evaluating tasks that can be automated to save time, such as claim prioritization and data research. Despite automation, the negotiator’s skills are still crucial for the actual negotiation process, where human judgment and communication are required.”

Simply put, technology is effective insofar as it augments a negotiator’s ability to be more efficient and productive. It is not a replacement but a means of giving staff actionable intelligence to empower their decision-making and provide ample time to communicate with providers.

“The focus is on enhancing the efficiency of our experts by providing them timely and relevant information,” adds Will Israel, Vice President of Portfolio Management & Product Integrations at Zelis. “This eliminates the need for them to spend extra time searching for data. The aim is to optimize workflow through system consolidation and data integration. Artificial Intelligence serves as a tool to achieve these objectives.”

A modern approach to claims negotiation must eliminate much of the administrative burden tied to repetitive tasks that technology is better suited for, especially with the maturation of natural language processing for data extraction and machine learning for pricing optimization.

“The objective is to apply these technologies where they are most effective,” says Israel. “Automation is used to simplify tasks and improve the workflow for internal end users. Having a bot consistently pull down updates from a website ensures our associates always have the most up-to-date information. The goal is to enable knowledge workers to focus on more meaningful tasks that require human expertise. Automating mundane tasks makes the work environment more enjoyable and efficient for associates."

Enabling that human element to thrive supported by technology and artificial intelligence has proved invaluable as claims volume grows and maintaining a sufficient workforce remains an obstacle in the way of keeping pace.

“Claim volume has increased significantly, but technology can assist in the negotiation process by providing relevant information quickly to truly understand the net cost of that claim considering both financial and clinical components. This helps negotiators decide how to approach each claim. The system also helps assign claims to the negotiation team based on factors such as time zones, claim value, and the last interaction with the provider,” Chang reveals.

“Negotiators use this information and historical experience to decide on their approach,” he continues. “Different providers may require different negotiation styles based on their personalities. Once a negotiator successfully negotiates with a provider, that provider becomes part of their portfolio to maintain rapport. This familiarity can sometimes eliminate the need for verbal negotiations in future dealings with the same provider.”

According to Chang and Israel, employing an in-house team for claims negotiation can be costly for payers in terms of recruitment, training, and overheads, whereas choosing a strategic partner can lead to cost savings while enabling access to a team of experts specialized in claims negotiations and the latest industry practices.

By working with a strategic partner for claims negotiations, payers can tap into the human and artificial intelligence needed to foster trusted relationships with providers and avoid burdening members with expensive care costs. Despite technological advances, human skills remain crucial for negotiating with providers. Having remarkable people provide remarkable service allows health plans to concentrate on their core business and strategic initiatives around network design and member engagement, all while bolstering payment integrity.

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Zelis is modernizing the healthcare financial experience by providing a connected platform that bridges the gaps and aligns interests across payers, providers, and healthcare consumers. This platform serves more than 700 payers, including the top-5 national health plans, BCBS insurers, regional health plans, TPAs and self-insured employers, and millions of healthcare providers and consumers. Zelis sees across the system to identify, optimize, and solve problems holistically with technology built by healthcare experts – driving real, measurable results for clients. Learn more at Zelis.com and follow us on LinkedIn to get the latest news.