Navigating Payer Challenges - Cover

Navigating Payer Challenges

In a previous post, I discussed the number one problem that my provider friends face: finances. This week, I want to talk about the fourth most common issue that has been brought to my attention: payer challenges.

Providers talked to me about several problems they had with payers this last year. I’ve listed some of the specific frustrations below.

Payers Dictating Care

Providers often brought up frustrations regarding their approach to a patient health being dictated by payers. Providers working in imaging specifically mentioned this concern as their biggest frustration. A radiology manager spoke specifically about the difficulties of handling authorizations:

“I am the project manager over outpatient services that deals with radiology, and authorizations are the biggest challenge that we run into. A physician wanting an authorization for a patient isn’t always enough. We have to go through all these hoops to get things addressed.” 

Providers may not be able to remove any of these hoops, but certain tools may act as a springboard to make jumping through the hoops a little easier. They can also work to create stronger relationships with payers.

Lack of Data Transparency

Providers who are in the process of trying to better understand the patients that don’t come through their doors are often attempting to bring in claims data. That information is not always complete or given to the providers in a timely fashion. A strategic planning director summed it up this way:

“Our biggest problem is getting the commercial payers to give us complete data through the claims feeds. There are so many different requirements for different areas and payers. All of that makes it really difficult for us to get good, clean, complete data from the commercial payers. Oftentimes, we see missing files, and the vendor has to work through us to facilitate a conversation with the payer, or they have to reach out to the payer directly to figure out where the missing files went. That is time consuming.”

Luckily, some data vendors have helped to reconcile providers and payers to ensure that both sides have accurate data for risk assessment and patient engagement.

Changing Reimbursements

Changing reimbursements may be the oldest and simplest frustration that providers have with payers. Each time providers think they’ve figured out a simple and efficient process by which to get paid, the rules seem to change. One pharmacist cited the importance of technology that helps mitigate these issues:

“Our billing office can be pretty casual about writing things off, and this system helps prevent billing and reimbursement problems, whether they have to do with changing numbers or a particular reimbursement policy. We can track and prevent a lot of those types of problems.”

Vendors who are closely following regulatory organizations and payer trends may be ready to lift at least part of the provider burden surrounding reimbursement.

 KLAS Resources

  • If you want to decide which vendors can make the most of your reimbursements and help with denials, check out the Claims and Denials Management 2017report; there are many good vendors for you to consider.


  • Providers in a position to influence payers could also make recommendations for technology that is built to help payers. The Payer Quality Analytics 2017 report shows which vendors can offer the fullest service to close gaps and improve quality.


Vendors Helping

  • ZirMed was a top overall performer in the Claims and Clearinghouse 2016 report and was part of long-term plans for 100%of their customers.


  • Health Solutions Plus won Best in KLAS in Payer Claims and Administration Platformsin 2019.


  • TrueView from Change Healthcareis the highest-ranked tool in KLAS’ lineup of Healthcare Price Transparency solutions.


  • MedInsight swooped in to win Best in KLAS in Payer Quality Analytics in 2019.


  • Verscend Technologies offered the most usable product in the Payer Quality Analytics 2017 report and had the highest overall score for performance and proactive guidance.


As providers feel the pressure to move toward greater risk in their value-based contracts, these pains that have always existed are being felt more acutely by payers.

Ultimately, providers are looking to payers to be tight-knit collaborators for a future in which providers take on more risk and patients are more deeply engaged in their care. Communicating about problems and potential solutions may be a great place to start.