Healthcare payers and facilities all want to ensure patients get the best level of care at the best possible cost as quickly as is feasible when it is needed – on that, everyone can agree. But there are differences – some small, some more glaring – between the way both sides operate that have led to an occasionally challenging, perhaps even slightly antagonistic relationship.

A survey from the American Hospital Association in 2022 showed that 78 per cent of providers felt their relationships with insurers were getting worse, with only one per cent thinking those relationships were improving. In addition, 84 per cent said the cost of complying with insurer policies was increasing, and a huge 95 per cent said staff time was increasingly being spent seeking prior authorisation, whereby US healthcare providers must gain approval from a patient’s insurer before offering them certain medications or medical procedures.

Those are not reassuring figures for anyone looking to confirm a good relationship between insurers and providers. On the plus side, it shows that there is plenty of scope for improvement for both parties, and lots of potential places to begin that journey.

Limiting risks

The insurer/provider relationship is absolutely critical in the realm of medical bills and treatment

Understanding what the other party is motivated by and what they seek to achieve would be a good starting point. At the most basic level, everyone would probably concur that payers want to limit risks and reduce any costs from unplanned care or from delayed, suboptimal, unnecessary or inappropriate care. When it comes to data, they examine risk information and share that across providers to help them make decisions.

Providers, on the other hand, are the ones caring for patients, and they hold clinical, evidence-based data about conditions and treatments. They employ the clinicians providing the care and work directly with the patients receiving it, with everything they do taking into account the individual’s requirements and risks as well as broader evidence.

The two parties start at different points, but both are essential when it comes to swift, effective, timely medical treatment for those who need it. That means the relationship between the two should be established and not just maintained but promoted, in order to ensure great care for patients and smooth operational processes for everyone.

“Insurers and providers are both essential players in the healthcare system, and they need to work together to ensure that patients have access to quality care at a reasonable cost,” said Dr Fatih Mehmet Gul, CEO of Dr Soliman Fakeeh Hospital Jeddah in Saudi Arabia. Dr Gul takes a dual perspective on the challenges presented by this relationship, thanks to his experience in the world of business leadership, along with his background in medical care. “Working together streamlines the claims process, negotiates fair reimbursement rates, and provides patients with information about their coverage and out-of-pocket costs,” he said.

“The insurer/provider relationship is absolutely critical in the realm of medical bills and treatment,” said Agathi Kanellou, Managing Director of Medical Claims International. With a commercial and strategic oversight of the company, she sees her role in the business as working alongside her colleagues to attain what she describes as a harmonious equilibrium between patient satisfaction, client outcomes, and provider support. That means she takes into account the company’s cost control, the highest standards of care for patients, optimal financial outcomes for clients, and the needs of clinicians. It is a tough balancing act, and one that requires careful negotiation.

“We place significant emphasis on this relationship. Our approach involves meticulous case reviews, proficient translation of medical reports and invoices in multiple languages, and strict adherence to the highest industry standards. This relationship is paramount as it underpins a seamless experience for patients, insurers, and providers alike. Finally, we hold the belief that engaging the insurer in the dynamic strategic planning process is crucial, ensuring optimal outcomes for all parties concerned.”

The challenges faced by these partnerships can vary significantly based on the countries of operation.

“One of the primary challenges is the differences in healthcare systems and regulations from one country to another,” said Kanellou. “These differences can introduce complexities into the partnership dynamics.

“Understanding the local healthcare landscape is crucial to adapt and cater to the unique needs of each region. While the core principles of insurer/provider relationships remain the same, the approach often needs to be tailored to align with the specific requirements and regulations of each country.”

Dr Gul agrees. “For example, in countries with single-payer healthcare systems, the government typically plays a larger role in regulating insurer/provider relationships. In countries with multi-payer healthcare systems, there is more competition between insurers and providers, which can make it more difficult to negotiate agreements.”

Dr Joseph Lelo, Medical Director of AMREF Flying Doctors, added: “Facilities in different countries will have different expectations of the payer. In some countries there may be mistrust of foreign unknown entities who may guarantee payments and the patients will be asked to pay in cash and claim from their insurers later.”

Looking for solutions

But there is plenty that can be done to improve the challenges the partnerships face, wherever they are in the world – and although it might not be a straightforward fix, it offers the sector the opportunity to come up with some creative and innovative solutions, as Kanellou said: “To enhance and improve these partnerships in the international healthcare arena, a multi-faceted approach is necessary.”

Using data better would be a great first step. Providers and insurers alike gather data, but they have different requirements and they put it to use differently, so it could be possible to think of ways to share data across parties and ensure that everybody on both sides knows what they need to know. That way there would be less confusion, and fewer phone calls and emails chasing all the information needed.

As Kanellou explained, “standardising billing processes and promoting transparency can eliminate many of the common issues that arise”. When providers collect clinical data and payers get claims data for billing purposes, that leaves both sides trying to match up or aggregate all the information they need. Being able to share some information would reduce this kind of duplicate administration, and could also help clinicians access medical data from other providers about patients when required.

Working together streamlines the claims process, negotiates fair reimbursement rates, and provides patients with information about their coverage and out-of-pocket costs

Dr Gul would like this kind of cooperation to be encouraged, and points out that some data sharing may already be happening thanks to steps taken by governments to make processes electronic and slicker. This is the case in Saudi Arabia, where the government’s rollout of Vision 2030, a programme to promote the economic, social and cultural diversification of the country, has the goal to increase the quality and efficiency of healthcare. That includes investment in personnel, facilities and infrastructure, of course, but also in technology that could help insurers.

“The Kingdom is investing in e-health services, such as telemedicine and electronic health records,” Dr Gul said. “This is making it easier for patients to access care and for providers to share information.”

Government involvement in healthcare, he added, also has a knock-on effect for the insurer/provider relationship – not least because it introduces a new party contributing to delivery of care and performance in the sector.

As well as governments investing in initiatives, Kanellou would like to see both insurers and providers invest in multilingual support, which she says “is crucial to address language barriers and facilitate effective communication between all parties involved”.

That is a vital point. Conversation, collaboration and knowledge are key. The American Hospital Association has said that it wants to see patients getting the healthcare they need, and clinicians able to do their work, without any delays or ‘roadblocks’. That is, in fact, what everyone involved wants to happen – so trust needs to be built between all parties, and that can only come through strong, clear communication.

“The insurer needs to communicate promptly and in detail as soon as the client is in need of service, and the provider will need to provide the service as directed and within the cost ceiling if it is indicated,” said Dr Lelo.

Dr Gul suggested that sound, clear guidelines to support insurer/provider relationships would be a great development, while Kanellou thought this could even go a step further.

“Providing education and training for insurers and providers can bridge the knowledge gaps and enhance collaboration,” she said. “This ensures that everyone is on the same page regarding best practices and local regulations.”

That information exchange could also include employers, the biggest sponsor of claims, who should be kept updated; and patients themselves, so they understand exactly where all the stakeholders in the process are coming from, and what they actually do. It could even be that they, or even the providers, aren’t fully aware of all the extra benefits they might have in their plans – so sharing information between all parties involved could be really helpful.

A streamlined approach

Even when insurers and providers are operating in different countries, there could be ways to reduce the potential issues caused by local rules and regulations. For example, the American Hospital Association has called for the standardisation of prior authorisation requirements and processes, including increased transparency on the services that require it, a standardised format and process for sending and responding to requests, making sure that responses are sent as quickly as possible, and dealing with denials appropriately and in sufficient detail.

Standardising billing processes and promoting transparency can eliminate many of the common issues that arise

In a 2022 survey by the American Medical Association, 94 per cent of physicians said that the prior authorisation process had delayed giving patients necessary care, and that in some cases these delays had meant people remaining in an inpatient facility that was not best suited to their requirements, the payment for which was not covered by their policy. Add to this the staff hours and costs it takes to deal with this necessary piece of administration – on both the insurer and the provider side – and it becomes apparent that a quicker, more streamlined, universally understood approach to dealing with it could surely be a positive move.

Ultimately, everyone involved wants the same thing – great care, delivered in a timely manner, at an appropriate cost – so ensuring the best working relationships possible is in everyone’s interests.

“It’s about fostering a culture of cooperation that values the wellbeing of patients above all else,” said Kanellou. “Regardless of where they are in the world, patients should receive the best care possible, and these partnerships play a pivotal role in making that a reality.”