Advisory Board: Hi Shawn, thank you so much again for joining our conversation today. We’d love to get started by hearing a little more about your role and HFMA. What are you working on?

Shawn Stack: My name is Shawn Stack and I'm one of the four policy directors at HFMA. I focus on reimbursement and revenue cycle issues as well as bridging the gap between revenue cycle financial folks in the hospital financial departments and clinical care folks. Right now, our team is working to put together a national payer [or health plan] scorecard for our members, which will come out this fall.

HFMA builds and supports coalitions with other healthcare associations and industry groups to try and achieve consensus on solutions that challenge the U.S. healthcare system today. We have over 117,000 members currently, mostly made up of providers and hospital organizations. We bring those healthcare leaders together to offer guidance and support healthcare financial professionals and coalitions to strengthen healthcare as a non-lobbying, bipartisan association.

AB: Thanks for that background! We know that many providers are making health plan scorecards at the organization-level at this point, but you're one of the few trying to make a standardized scorecard at the national level. What are the benefits of these standardized health plan scorecards over a more individualized organization-level scorecard?

SS: Our approach to a national scorecard is extremely important for both payers and providers.  I hesitate to call it a payer scorecard because I think it's important that health plans and providers are weighted equally in the responsibility for payment and claims reimbursement performance. Building a national, uniform, apples-to-apples comparison should assist all stakeholders in collaborating and learning from each other. Concern over healthcare costs is something that both payers and providers are interested in controlling. This includes the administrative burden that comes along with those costs and associated quality of care metrics. But we need more national focus on collaboration and effective tools to facilitate that collaboration.

That's where HFMA hopes to make a big difference. Nationally, there are other good scorecards on the market, but I think HFMA's national scorecard, and our close collaboration with those other scorecards on the market, will help fill in some of the gaps that others aren’t addressing and make sure that providers are reporting key data metrics uniformly or as close to uniform as we can get. We're focusing on filling the gaps to provide a tool that helps facilitate collaboration, alleviate communication breakdowns and administrative burden, and most importantly, improve timely access to care, which seems to be a bigger issue right now than it has been in the last couple of years.

AB: I appreciate the way you framed this as a payer-provider scorecard to emphasize that this can help reveal and relieve challenges for health plans and providers alike. Do you generally think that the scorecard will be more useful for providers than health plans, or do you think this is going to produce an equal benefit for both?

SS: I think that's going to depend on the success of how we structure the scorecard. Payers and providers typically don’t successfully educate each other on the issues they see with the workflow process. If we structure the scorecard in a way so payers can get just as much information from it as providers, it will help both parties educate each other on their workflows and the bottlenecks that impact them — like getting patients preauthorized for care, discharged to a post-acute care facility, or getting claims reimbursed with minimal administrative burden. As we finalize our scorecard, we’re working closely with our members, payers, providers and other scorecards to establish what metrics are needed to facilitate that education.

We’re still figuring out the ideal structure for the scorecard and need more input from payers on what they want included. We need to know what payers want tracked so they can educate providers to not unknowingly make the same mistake time after time. At hospitals, we take the findings we capture in the billing process — around denials, rejections, and missing information — back to physicians to tell them what’s missing and the administrative error it’s causing. I'm hoping this payer scorecard will help set up a similar type of dialogue between payers and providers. For example, what if a payer is denying something 80% of the time because you're not including an authorization number even though you secured an authorization? We want to identify and provide feedback so the providers can correct the issue and alleviate administrative burden on both the payer and provider.

AB: Have you identified anything that health plans should be doing to prepare for these conversations? Should they be beefing up their own data analytics or just preparing to share data with providers?

SS: I think payers should be preparing the right data to share with providers and preparing to work more collaboratively with other payers to improve their performance. I helped set up a scorecard with a large provider group in the state. Once a quarter, Medicaid payers got together in the same room and the providers went over all the issues they had with each payer, in front of the other competing Medicaid payers. The payers got so much information learning about other payer’s issues that they’d go back to the providers and say, “Hey, we weren’t called out for this issue, but is this happening, and we just don’t know about it?” It was a joint education session for everyone.

AB: It sounds like the comparative functionality is going to help prompt those conversations between providers and plans. Can you describe what that could look like?

SS: What I’m hoping this national scorecard will be able to do is say, “X hospital has an issue with Y plan. Let’s look and see if other hospitals in our state that contract with this plan are having the same issue. Is it a common issue that could be payer related, or did the other hospitals not have this issue, and maybe it’s just us?” It will help give providers an idea of broader trends in their market or their state.

You could also look at payer performance nationally, since something might happen in a different region that could forecast trends to come in your market. Let’s say hospitals saw prior authorizations go through the roof with a certain payer on the West Coast, but no one on the East Coast sees that with this payer. Did the payer introduce a policy out west they haven’t introduced on the East Coast yet? This gives providers and payers an opportunity to reach out to others to hear what’s happening and to prepare and educate early.  

AB: You've talked about how providers can use scorecards internally to fix some of their processes and how they can drive accountability with plans. Are there benefits to health plans beyond providers fixing their own internal processes with the scorecard?

SS: I think we could eventually see blinded information sharing from this scorecard. Let’s say a hospital is contracted with six Medicare Advantage plans and is having a conversation with one of them. They can share the blinded data about the challenges they’re also having with those other five plans. For the plan in the room, the information sharing can help them proactively get ahead of issues that might be coming down the pike. It’s exciting how many things we could do to work more collaboratively through a national scorecard like this.

It's also worth pointing out that some of the things that eliminate administrative burden from the provider can also reduce administrative burden and costs for the payer. For instance, a payer requires prior authorization for a radiology procedure, but a provider using the scorecard realizes the payer approves the prior authorization 98% of the time. They could take that data to the payer and ask them to stop requiring prior authorizations for that procedure. Instead, they could give the payer access to retroactively review, thus lifting the administrative burden of having to review those prior authorizations.

But this also works the other way. If the payer isn’t willing to relieve the provider of a prior authorization with a very high approval rating, the provider could come back and ask for an increase in contractual rates because the payer is requiring an unnecessary administrative burden. So, it’s a give and take, but it provides open dialogue backed with real data.

AB: You’ve painted a promising picture for this national scorecard. Have you identified any barriers to adoption?

SS: There are always a lot of barriers to adoption when you're working with a provider, or a payer, who doesn’t have time to get through everything in their day. We’re trying to put together a scorecard that is more useful than current scorecards out there, or at least compliments them, and can stand on its own without adding a ton of administrative burden to the hospital. Figuring out the sweet spot of greatest benefit with least lift is what we’re working through now. 

AB: Thanks for sharing so much about your work and HFMA’s national scorecard ambitions with us. In closing, do you have any words of advice for plans and providers that are hoping to improve their relationship?

SS: I just had this conversation with providers. Make sure the issues you have with payers are valid and still occurring before you take them to them. Make sure those issue logs are up to date, so you don't lose credibility on why you're bringing them to the table to discuss with both parties.

For health plans, I think my main advice would be to think about improving your education on your medical policies — the areas that providers tell you are very gray.  If you’re not clearly defining medical necessity criteria to your providers, you're just setting yourself up for more administrative burden. I think better clarity and policies are needed on both sides.

Consider how comparative scorecards can:

• Play a key role in your strategy to address the root cause of degrading plan-provider relationships.
• Keep health plans and providers accountable to their contracts and prompt problem-solving action from all sides by fostering increased transparency and collaboration.
• Help health plans compare their performance to other plans and identify improvement areas.
• Proactively address plan-provider pain points before they escalate and identify points of reconciliation.

HFMA’s scorecard will be published later this year. In the meantime, here are 10 metrics every hospital should track as part of their efforts to monitor health plan performance.