Provider abrasion. It’s no mistake the term itself sounds like a medical condition. In fact, clinically speaking, an abrasion is a scrape. More specifically, according to Cleveland Clinic, “An abrasion often happens when something hits or drags against your skin (friction). Abrasions are usually accidental injuries.” Nothing a band-aid can’t fix.

When it comes to provider abrasion, however, we’re talking about a different kind of friction— friction between providers and health plans. But does anyone actually really know what it means? After all, the term isn’t really even used by providers themselves. 

But, as health plans know it, provider abrasion is the result of any process that delays or hinders providers’ primary task of delivering care. It comes in all shapes and sizes but is, for the most part, a preventable disease. (Ironically, sometimes providers bring it on themselves.) Provider abrasion not only breeds inefficiencies and mistrust, but can also ultimately trickle down and impact the quality of care delivered to patients. 

Understanding the root causes of provider abrasion and finding ways to reduce it—not just slap a band-aid on it—is crucial for improving relationships between providers and health plans.

What Causes Provider Abrasion?

Being a little more severe than a boo-boo, several factors contribute to provider abrasion. After all, healthcare is a business. With billions at stake providers are pushing the limit on what they submit. Claims may be manipulated and medical records could get twisted, all in the name of profit. But, at the same time, health plans have a fiduciary responsibility to pay the correct price for all services. 

Plus, when adding in complex policies, claim denials or delays, and inadequate communication between health plans and providers, the chasm caused by provider abrasion only widens. 

1. Complex and Inconsistent Policies

Health plans often have varying policies, processes, and requirements for claims submission, reimbursement, and patient eligibility. Providers are really looking for the TL;DR, the important information that tells them what they need to do, and how to do it. 

Imagine a policy that requires prior authorization for a high-cost injectable medication. The policy includes multiple layers of requirements: a detailed medical history, specific lab results, proof of failed alternative therapies, and even documentation of patient adherence to previous treatments. While these safeguards make sense to manage costs and ensure appropriate use, the policy lacks clear instructions on how to submit the information or what qualifies as sufficient documentation.

From the health plan’s perspective, this generates unnecessary follow-up calls, additional claims processing, and strained provider relationships. Plus, when you take into account that prior authorization denial rates are 4-6% on average (meaning that 94-96% of prior auths should never happen), it’s a whole lot of hoopla for nothing.

2. Claim Denials and Reimbursements Delays

One of the most common sources of provider abrasion is the review and denial of claims, which can happen for various reasons, including the aforementioned complicated policies, coding errors, lack of required documentation, or failure to meet prior-authorization criteria. 

Let’s say a cardiologist performs a stress test on a patient to evaluate potential heart disease. The procedure was straightforward, but the claim is denied payment by the health plan. An incorrect billing code was used—which wasn’t clear from the initial denial notice.

The cardiologist’s office now has to 1) investigate why the claim was denied, spending hours on hold with the health plan’s customer service, 2) resubmit the claim with revised documentation, hoping the updated code resolves the issue, and 3) wait weeks or months for reimbursement, while the costs for the procedure (staff time, facility use, etc.) remain unpaid.

When claims are denied, providers not only have to invest additional time and resources to appeal and resolve the denial, but even when claims are approved, delays in reimbursement can stress providers' cash flow and financial stability.

3. Low Visibility

The healthcare system as a whole is a bit . . . opaque. Providers don’t have visibility into the status of claims, reasoning behind audits, or even timelines of audits. The lines of communication between health plans and providers are not as open as one might hope. 

It’s important to remember that providers likely aren’t only dealing with your health plan. It’s gotten to the point where—true story—some providers even have over 34 different payer portals bookmarked in their browser.   

Effective communication between providers and health plans is essential to addressing issues promptly. However, providers often encounter difficulties reaching health plan representatives, which delays the resolution of questions or issues regarding claims and payments. Inefficient or ineffective communication channels can exacerbate existing frustrations and add to provider abrasion.

For example, consider a provider who needs to refer a patient to a specialist for an advanced diagnostic test. The health plan requires prior authorization, but the process for obtaining it is unclear. The provider’s office attempts to contact the health plan through the provider portal but finds the instructions vague and incomplete. They then call the provider support line and are transferred multiple times, receiving conflicting answers about the required documentation and submission process.

After finally submitting the authorization request, they receive no confirmation for several days. When they follow up, they're told the request was denied because it lacked a specific detail not mentioned during previous interactions. They then have to start over.

How to Reduce Provider Abrasion

If only a band-aid could work for this sort of abrasion. In reality, reducing provider abrasion requires a multi-faceted approach. Implementing a strategic plan can foster more collaborative and positive interactions between health plans and providers, ultimately benefiting patients and the healthcare system as a whole. 

1. Streamline Administrative Processes

No surprise here, but establishing clear policy guidelines and consistent processes is a huge factor in reducing provider abrasion. This directly addresses the concerns over complex and inconsistent policies.

Consistency in policies and processes across different plans and products can help providers avoid confusion and unnecessary errors. Health plans should aim to implement standardized guidelines, especially for frequently disputed areas like pre-authorizations, documentation requirements, and claims adjudication.

Ensuring that these guidelines are updated regularly and clearly communicated to providers helps build a foundation of trust. Providers are more likely to engage in positive and cooperative relationships with health plans when they understand what is expected of them and can rely on consistent processes.

2. Enhance Payment Integrity

To directly address claim denials and payment delays, health plans should consider improving their payment integrity programs. Payment integrity, which refers to the process of ensuring that healthcare payments are accurate, appropriate, and compliant with all regulations, involves verifying that providers are reimbursed correctly for the services rendered while preventing fraud, waste, and abuse (FWA). 

Today, many plans use tools that rely on vague, broad criteria for selecting claims to audit. For example, a rule could be “any claim over $100,000 should be reviewed.” But what if that is a perfectly legitimate claim? In an improved payment integrity program, health plans can employ tools that use more intelligent claim selection with hundreds of specific, detailed rules that automatically determine whether or not a claim should be audited. 

Not to mention, with the use of AI, these tools are learning and improving. So, if a provider is audited once, but the claim was legitimate, perhaps going forward a similar claim wouldn’t be pulled for auditing—essentially rewarding the provider for good behavior. 

When providers experience a higher rate of accurate and timely payments, their trust in the health plan increases, reducing friction and promoting a more positive relationship.

3. Leverage Technology for Better Visibility

Technology can play a vital role in addressing inadequate communication channels and transparency. By enabling efficient data sharing and better insights into claim statuses, patient information, and reimbursement rates, health plans can reduce provider abrasion. 

Advanced technologies, including AI and interoperability solutions, facilitate seamless information exchange between providers and health plans, which can significantly improve efficiency and reduce errors.

Tools that allow real-time updates on claim status or prior authorization decisions empower providers with the information they need to manage patient care and administrative tasks more effectively. This transparency reduces the likelihood of frustration and delays due to lack of information.

Why Bother Fixing it?

Okay, big whoop. Who cares if providers are a bit miffed with the process? Well, aside from damaging relationships with providers that keep your plan afloat, the bottom line is . . . well, it could also severely impact your plan’s bottom line. 

For one, providers can choose to opt-out of your health plan. If they’re feeling the strain from administrative burden or overwhelming policies, they can stop accepting patients covered by your plan. Losing trusted providers can ruin your plan’s reputation. Plus, if the providers you do retain are bogged down with paperwork, they may not be able to provide the highest level of care, another blow to your plan’s reputation. 

Then, there’s operational efficiency to consider. With high levels of provider abrasion, there’s a lot of problem-solving that needs to be done. Calls to customer service, filed complaints, etc. Not to mention the fact that too many complaints can catch the eye of regulators. 

Don’t get us wrong, post-service audits are a necessary element that requires providers to prove that the diagnosis and care rendered on the claim are accurate. There’s necessary abrasion— health plans audit the cases that require auditing. Not every case. Not even 50%. Audit systems should be calibrated to understand which cases from which providers require attention. 

Now we can all agree unnecessary provider abrasion is something that’s better to avoid. Streamlined claims, enhanced payment integrity programs, and a touch of transparency go a long way. At the end of the day, happy providers mean healthier patients and fewer billing disputes draining everyone’s energy. Sounds like a win.

If you’re interested in learning how Machinify’s AI-powered Audit and Pay can reduce provider abrasion for your health plan, schedule a demo today. 

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