How to Build Better Relationships with the Health Insurance & Payer Communities

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Dr.

Modern healthcare is a complicated dance between quality and quantity.

Payers and insurance providers want better patient outcomes because of the high cost of poor health, while health care providers want to ensure that their patients are not overlooked and are properly cared for.

To understand how we can meet the needs of both patients and payers, we will need to take a step back and look at the relationship between the payer communities and telehealth services.

Behavioral telehealth is here to stay

The concept of telehealth has been around for a while, but it didn’t become the mainstay we know today until the pandemic. Before 6 Feet Apart, few insurance companies recognized the importance or necessity of virtual care. So even if the argument sounded convincing, it was too bold. Now, if you were to ask behavioral health individuals how they view providers, they would most likely mention telehealth as an option.

In other words, telehealth is here to stay. However, several barriers must be addressed to ensure that patients receive quality care while reducing medical costs for insurance companies.

An important component of quality health care involves the balance between quality and quantity. Telehealth providers must see a number of patients each day, but as the number of patients increases, quality measures must be implemented to ensure that each patient receives the best care.

For example, it is sometimes challenging to quantify behavioral health outcomes. However, with quality operating procedures in place, you can ensure that each patient receives more comprehensive and comprehensive care that reduces the use of medications such as antipsychotics and benzodiazepines. High-risk psychotropic medications pose the greatest threat and can lead to more negative outcomes, ultimately resulting in higher costs for the insurance provider and payer community.

Is Behavioral Telehealth Really Worth It?

Telehealth has many benefits; for one, it exponentially reduces costs for patients, families, facilities and insurance companies. For patients, this allows them to visit general practitioners and specialists without leaving their homes. Seeing specialists remotely cuts gas, time and on-site personnel costs and opens up patients to specialty care nationwide.

Not only does Telehealth help reduce costs, it also helps to see patients more often. Frequent virtual medical treatment significantly reduces the likelihood that patients will be sent to the hospital, which is often costly for insurance providers. In addition, it expands the scope of care with trained providers and can properly diagnose behavioral issues and treat individuals with mental health conditions through a patient-centered approach using clinical protocols.

Older adults and individuals with behavioral health problems may experience a higher rate of mental health conditions and behaviors, including mood disorders such as Depression or Bipolar Disorder, Anxiety Disorders, Post-Traumatic Stress Disorder ( PTSD) and Psychotic Disorders. However, these patients are often misdiagnosed with a mental health condition due to maladaptive symptoms and behaviors. These misdiagnoses can lead to inappropriate use of medications, such as the prescription of high-risk antipsychotics. Regular visits with behavioral health patients via telehealth ensure that patients are treated with appropriate and safer medications, also expanding each institution’s bottom line.

The health care system also suffers from a shortage of providers and care, so it’s no surprise that more digital tools and teletechnology services are being used to expand reach and provide care to underserved groups.

So is telehealth worth it? Providing accessible, patient-centered, high-quality virtual care is the perfect solution for patients, their families, their facility and their insurance provider. As a result, payers welcome telehealth and related practices as it benefits patients by increasing access to care, managing misdiagnosis, and reducing insurance costs by avoiding further unnecessary health complications.

Normal does not always mean optimal.

In most situations where telehealth is used, patients visit their clinician/specialist, the clinician writes clinical notes that trigger a billing code, and the insurer covers the costs. While efficient, it still has its drawbacks. Quality is left to the clinician and the clinician alone. Nothing else protects patient care.

Telehealth clinicians can often be sent to see patients with little or no support, yielding costly and sometimes dangerous health outcomes. However, measures can be taken to ensure that patients receive quality specialist care. Implementing quality operating procedures in telehealth practices ensures that clinicians are supported and well-equipped to handle individual behavioral health care.

It begins with hand-selection of clinicians during hiring/boarding and continues through a credentialing process that ends with rigorous internal approval. To provide the best care, clinicians must be supported, trained and provided with continuing education.

With quality standard operating procedures, insurance providers don’t need to worry about the quality of each patient’s care or whether patients will be hospitalized due to misdiagnosis or unsafe medication use.

Policies and Procedures Front and Center

How can you implement structures to ensure standardized, quality and accessible telehealth services? First, let’s talk about URAC accreditation. URAC is an organization that is responsible for developing quality standards for the entire healthcare industry. The accreditation process is used to set high standards for a health care organization’s systems, procedures, and techniques that the organization must meet itself.

Payers and insurance providers typically seek to partner with organizations with URAC accreditation as it is synonymous with quality care. It provides a mark of distinction for healthcare and demonstrates the company’s commitment to quality, which means improved patient health outcomes. The financial benefits of accreditation are also twofold: Increased patient volume leads to increased revenue, and Medicare payments to accredited facilities are maintained due to proper patient status determination.

While it is essential to have URAC accreditation, facilities can also continuously monitor and implement policies and procedures that ensure practices are within the bounds of laws and regulations. Procedures reinforce quality standards. For example, behavioral health patient screenings are a common practice that can be used to screen and monitor patients. In addition, telehealth services help healthcare facilities control and monitor patients who often have large amounts of polypharmacy, where a patient may be taking more than one medication.

Patient reviews and tests are often an afterthought, but they are a good indicator of how well a patient is responding to medications, therapies, and other forms of intervention.

Behavioral telehealth cuts costs

Although virtual health care has grown significantly in recent years, the payer community and insurance providers have yet to fully exploit its advantages. Benefiting from trained providers who can properly diagnose and treat behavioral issues through a patient-centered approach using established clinical protocols lends itself to healthy patients. This ensures that patients are treated with appropriate and safe medications, even non-pharmacological options when possible, reducing the risk of adverse outcomes such as hospital admissions and medication side effects.

Telehealth is a great place to start if payer communities and insurance providers are looking to work with a high volume of patients while also practicing quality care techniques. Enabling proactive/frequent clinical visits, taking steps toward URAC accreditation, and implementing quality procedures and policies using telehealth drastically reduce the financial burden on payers and insurance providers in the health care system.

About Dr. Jessica Badichek, PharmD, BCGP

Dr. Badichek completed her undergraduate studies at Fairfield University in Connecticut and her Doctorate of Pharmacy at the University of the Sciences in Philadelphia. She is currently Chief IT and Compliance Officer at MediTelecare. She previously worked at ComprecareRx Pharmacy (PursueCare) working with opioid use disorder patients and Arrow/Partners Long Term Care Pharmacy working with hospice and elderly patients. She has considerable experience and knowledge in all aspects of psycho-pharmacology and the use of psychotropic agents in geriatric populations.

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