In a complex and rapidly evolving healthcare environment, payer dynamics and regulatory demands are top concerns for healthcare leaders. Health systems are frustrated with payers’ selective interpretations of medical necessity, which often complicate the process of delivering timely, essential care to patients.
"Payer behaviors are really creating toxic health for our patients and our providers," Kathy LeBrew, executive vice president, chief transformation officer, and chief revenue officer at Minneapolis-based M Health Fairview, said on an episode of the "Becker's Healthcare Podcast." "We need more focus to hold them accountable and recognize the work our practitioners are doing in the industry today."
Managed care programs, particularly Medicare Advantage, have increasingly stringent criteria and protocols, placing substantial administrative and financial burdens on healthcare providers. These payer-imposed requirements, from prior authorizations to medical necessity reviews, delay care for patients and require considerable resources to navigate. Without payer accountability and cooperation with healthcare providers, Ms. LeBrew fears patient care and accessibility will be compromised.
She is also focused on compliance as regulations and policies at the state and federal level continuously change.
"Staying current and compliant are top of mind for us in the revenue cycle. It's one of our business imperatives, so we have structured ourselves, our resources, our technology to ensure we have the latest and greatest in understanding payer regulations, requirements and changes that are happening and understanding the impacts not only on our workers, but in our workflow and how it affects our patients as well," said Ms. LeBrew.
To address these compliance demands, Fairview has structured its resources and technology to monitor and adapt to regulatory updates as they occur. The organization’s revenue cycle team collaborates closely with its governmental affairs department, which helps ensure that Fairview remains proactive in understanding and implementing regulatory changes. Ms. LeBrew also noted the organization's reliance on advanced technologies to streamline the process, allowing her team to stay agile and compliant without sacrificing efficiency.
Ms. LeBrew emphasized that meeting compliance requirements isn’t just about avoiding penalties; it’s also about supporting patient care. To this end, Fairview uses data and technology strategically, aiming to streamline workflows and free up resources that can be dedicated to patient care. This includes using automated systems to handle payer regulations, freeing up staff to focus on higher-level tasks, and prioritizing patient-centered outcomes.
"We have structured ourselves, our resources and our technology to ensure we have the latest and greatest in understanding payer regulations, requirements and changes happening and understanding the impacts not only on our workers, but in our workflow and how it affects patients as well to make sure we're delivering top tier service performance and helping patients focus on what they should focus on, which is their health and wellness," Ms. LeBrew said.
This foresight allows Fairview to act quickly, avoiding costly disruptions and ensuring compliance without slowing down care delivery.