New physician paper: Resolving payor-provider tension in payment integrity

New physician paper: Resolving payor-provider tension in payment integrity

NEW YORK, Feb. 5, 2024 /PRNewswire-PRWeb/ — MedReview, Inc., a leading provider of payment integrity, utilization management and quality surveillance services, today released the whitepaper “Provider Abrasion is Healthy” by Chief Medical Officer Dr. Michael Menen. The whitepaper examines the strain that competing business goals place on relationships between payors and providers and explores how certain elements perceived as abrasive by healthcare providers may, in fact, be essential.

“Provider abrasion” results when the objectives of healthcare providers – to maximize revenue while providing high-quality patient care – conflict with payors’ goals of ensuring that care is appropriate, fiscally reasonable, and accurately documented on an insurance claim. These competing priorities can lead to tension between the two parties and, in some cases, a lack of cooperation.

“Provider abrasion is real, but it’s not inherently bad,” said author Dr. Menen. “Just like our neighborhoods are safer when drivers know that someone may be enforcing traffic laws, healthcare is less costly for everyone when providers know that payors are ensuring adherence to financial policies.”

Provider abrasion typically occurs between the provider’s finance department and the payor’s payment integrity unit, usually over diagnostic-related group (DRG) coding reviews and clinical validation, hospital bill audits, and readmission reviews.

What payors consider necessary steps for payment integrity, providers see as a drain on resources and a cause of diminished or delayed revenue. By placing provider abrasion in the larger context of the financial, staffing, administrative and regulatory strain that health systems face daily, the whitepaper paints a more complete picture of the environment in which payor-provider interactions take place. It offers novel, specific solutions to mitigate conflict and improve relationships.

“Payors can work with payment integrity vendors like MedReview to ease potentially volatile interactions with providers by using transparent, expedient solutions to lessen abrasion without undermining their payment integrity processes,” Dr. Menen says.

Dr. Menen, a former practicing cardiologist who also served as CMO of several leading health systems, is a featured speaker at the HPRI Congress South. He will be presenting “Provider Abrasion is Healthy” at 3PM E.T. on Wednesday, Feburary 7 at the event in Miami. In the session, Dr. Menen will explore strategies payors can use to make provider interactions more palatable while maintaining a robust and balanced healthcare ecosystem.

Read the full press release

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    About MedReview
    Headquartered in the financial district of New York City and serving all U.S. states and territories, MedReview has been a leading provider of payment integrity, utilization management and quality surveillance services for more than 40 years. A physician-led organization with a passion for ensuring that health care claims fairly represent the care provided, MedReview provides timely independent hospital billing audits and clinical validation reviews on behalf of health plans, government agencies and Taft-Hartley organizations, saving millions of dollars for its clients each year.

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