Provider Relations Unicorn

Prior to joining ClaimDOC in May of 2021, I spent most of the last 25 years negotiating transactions on behalf of health systems, hospitals and physician practices. These transactions covered all corners of healthcare including provider reimbursement, physician employment, joint ventures and healthcare mergers (all Stark and Anti-Kickback compliant, of course!). Like most in the healthcare administration and legal circles, the body of work ranges from very successful to complete duds.

I’d like to think my success rate was much higher than even the best MLB batting averages, but like most healthcare administrators and lawyers, I probably learned more from the losses than the successes.  One lesson etched from both the wins and the losses is that we must understand the value proposition we bring to the table. Knowing the value proposition is key to understanding leverage of yourself as well as other partners at the table. It also helps anticipate which are the good deals and which are the duds.

At ClaimDOC, the value proposition is very clear. It’s strategic plan management and effective relationships with members, clients, brokers and yes, even providers. My question when ClaimDOC hired me was the same that many of our broker partners ask: How does an RBP-based company, focused on staunchly defending their allowable, cultivate strong relationships with providers and create a smooth access experience without relying on contracts? In my short time at ClaimDOC, I see it working firsthand.

At ClaimDOC, we approach provider relations differently. We often hear we sound just like everyone else, however, a sales pitch and how you execute daily are two very different things. We push hard to dispel the myths and replace them with an understanding that effective provider relationships, even while we engage in tough negotiations, benefit our health plans and members in the long term.  As a result, we have a keen understanding of all aspects of our relationships before, during and after negotiations. We do this by focusing on the following:

Know our health plan and our members. We look at our customers and key on the providers their members have historically used. Through our Pave the Way™ program, we proactively identify key providers by asking our members for their input. Then, we seek partnerships with these providers. In addition, we also anticipate the specific healthcare needs of the members when targeting specialties and services and locations for care. For example, a health plan with younger, more active members may require ClaimDOC to seek relationships with a greater selection of family practice, pediatrics and orthopedic surgery. The key is to develop a plan tailored to the needs of our members.

Know the local healthcare landscape. ClaimDOC dives into the local healthcare market and identifies important provider-provider relationships in the market. For example, some markets are dominated by a few large health systems who are open to competitive reimbursement agreements. In other markets, the better approach is working with smaller, independent practices who are affiliated with successful hospitals. ClaimDOC gets to know these markets and capitalizes on the opportunities that our competitors miss with a quick fix, network-based strategy. This granular approach requires “boots on the ground” and hard work which is simply not in many competitors’ business plans.

Know what success looks like. At ClaimDOC, we measure our success against the triple aim (i.e., cost reduction, access to care and member experience). Rather than imitate marginal PPO networks or other strategies which focus on one component of triple aim, we are motivated to strike a balance among all three. We identify and partner with providers who share this devotion to the triple aim because we find that these are the providers willing to think creatively about the triple aim. With this innovative mindset, we don’t focus on a single form for our partnership because we are trying to create a platform for working collaboratively with our plans and providers in ways our competition wouldn’t consider. As a co-fiduciary for our plans, we commit to the hard work of innovation, and this ties well to providers who are also engaged in this hard work.

Know what makes providers tick. ClaimDOC understands how to approach providers to establish an effective relationship even in the face of pushback based on the number of covered lives or other familiar objections. We don’t stop at the first rejection with a provider we believe to be a great fit for our members. Instead, we persist in a way that keeps the doors to partnership open with honest, transparent communication. We understand that even the largest health systems are built around individual patient relationships, and sometimes it takes just one positive patient experience to bring providers back to the table. Again, this takes time to work one-on-one with providers, but this approach mirrors the care process, and it allows ClaimDOC to address changes in real-time.

Know what is possible. Finally, at ClaimDOC, we know that healthcare will continue to change. While our commitment to our health plans and our members will never waver, our relationships with our providers will evolve. As we bring our member-centric philosophy to the table with our provider partners, we believe there are endless possibilities, and we are actively exploring ways to help bend the healthcare cost curve. These efforts incorporate what providers have been developing for years, and unlike the large health insurance companies, we don’t force the provider to adopt a new data collection effort. We can bring health plans to the table to work directly with providers on a local, provider-patient level. These provider-led initiatives, often dismissed by large insurance carriers and ignored by our competition, create opportunities to deepen the relationships among providers and our members.

ClaimDOC values its relationships with provider partners because we understand they are the ones taking care of our members. Building these relationships is hard work, and despite the approach of our competition, there are no shortcuts. Our strategic use of contracts and resisting contracts of convenience yields results that are worth the extra time. Our clients enjoy great provider access and achieve greater program savings all with a superior member experience…the triple aim.