4 Obstacles To Value-Based Care In Provider Based Billing

4 Obstacles To Value Based Care In Provider Based BillingHealth plans need provider engagement with value-based care to boost their CMS star ratings and HEDIS scores, but most providers are still not getting on board despite continuing outreach and encouragement. Providers may want to participate, but they are held back by these obstacles:

  1. Smaller practices are still the majority. Nearly 60% of the nation’s providers serve in practices with 10 or less physicians(1), and smaller practices have less time and resources to keep up with care gaps and quality measures for each patient.

  2. Value contracts with health plans are too complex. Value contracts with health plans may provide guidance about quality measures, but they are not user-friendly. They are large, complicated documents that are hard to understand and require intensive effort to interpret and apply consistently within practices.

  3. Administrative workload is too high. Providers feel that they can’t free their staffs from other responsibilities to manage relationships with multiple health plans, including the paperwork, phone calls and follow-ups needed to implement each health plans’ value-based care reimbursement strategy.

  4. Financial incentives are not worth the effort. Clinical and financial quality information currently are not delivered together, making it more difficult for providers to understand the financial benefits that accompany clinical best practices.

Simple Solution for a Perplexing Challenge

Some of the nation’s largest health plans are taking notice of Payspan’s quality solution, which addresses the obstacles above. Payspan recently implemented a large health plan with 4.3 million members and is in the early stages of contracting with one of the top five health plans in the nation to deliver its innovative Quality Incentive Communications System (QICS).

“When we present the solution to health plans, they get really excited,” says Payspan’s CEO Rob Pinataro. “Realizing that our health plan clients were already communicating with providers about claims and reimbursements via our network, a natural extension of value is to leverage our network as a medical records exchange to reduce paper and accelerate the adoption of value-based care among physicians. The interest level by health plans of varying sizes validates our approach to Quality.”

Learn more about QICS in this Ebook. 

How QICS overcomes provider challenges:

  • Simplifies communications about quality measures. Providers and their staffs don’t have to spend exorbitant resources plowing through dense value contracts. QICS takes raw data from health plans and transforms it into clear, simple, visually appealing communications that providers can easily read notifying them about identified care gaps and the quality measures that need to be taken. Incentive reports provide a list of patients, care gaps and closure status, as well as the amount of the incentive for each closure. Simplified communications provide just enough information for providers to easily close care gaps and not too much to overwhelm them. The result is more gap closure and better member health.

  • Reduces paperwork, administrative workload and costs. Payspan leverages the largest healthcare epayments network with 600+ health plans and 1.3 million provider payees to enable the secure exchange of quality communications via attachments. Providers merely enroll, and they have instant access to multiple health plans. They don’t have to spend time enrolling and managing each plan’s process for each patient, or processing paperwork via snail mail.

  • Magnifies the value of financial incentives. With much less effort needed to organize and process the paperwork, the financial incentives being offered per quality measure may take on more value. What might have seemed like “small change” before could suddenly be perceived as a substantial addition to revenue. Now that providers are taking losses from patients who can’t keep up with their mounting payment responsibilities, these small incentives are well received to help counter the losses.

As the first company to build an entire network around facilitating EFT/ACH as the preferred payment option, Payspan is uniquely positioned to leverage this network to help health plans securely exchange sensitive medical information with their providers to advance quality-based care.

Learn more about QICS in this ebook


(1) American Medical Association, “Policy Research Perspectives: Physician Ownership Drops Below 50 Percent,” 2016