Up-to-date provider network directories enhance patient satisfaction and reduce operational costs. Yet health plans are facing several challenges to attract, retain and manage their provider networks due to manual processes, inaccurate data and poor communication tools.
These operational inefficiencies have a negative impact on provider experience, care delivery and patient satisfaction. Moreover, the Consolidated Appropriations Act of 2021 and state regulations require providers and health plans to validate provider data frequently to maintain accurate directories.
The processes to onboard, credential and update provider data are manual, long, opaque and expensive. As a result, PwC estimates that 50% of provider network directories are out-of-date or incorrectly list a provider as participating. There is an important operational cost for a health plan to credential providers as well as a reputational cost associated with having inaccurate provider data due to a substandard credentialing process.
Automation and technology enablers
Reimagining provider network management (PNM) involves looking at automation and technology enablement of processes across the provider lifecycle to improve data quality, optimize processes, and enhance value-added provider servicing.
When done right, effective PNM has significant potential both across and beyond the walls of a payer organization, including:
- Provider satisfaction: increase satisfaction and retention due to reductions in time required to process applications, contracting and servicing
- Operational efficiency: reduce administrative costs through automation of back and front office tasks
- Compliance: avoid regulatory penalties and sanctions for inaccurate provider data, failure to adhere to service level agreements and avoid loss of membership due to state and federal sanctions
- Affordability: reduce costs by enhancing claim adjudication using accurate provider and network data and reduce overall medical cost by collaborating with provider on health outcomes as well value based care arrangements
- Member experience: enhance self service and engagement by allowing members to access accurate provider details; improve cost transparency, enhance in-network provider recommendation and selection and improve STARS ratings
The eight steps to greater value in PNM modernization
While the opportunity is ripe for digital solutions, transformations are categorically difficult, and even more so in the case of PNM where organizations are managing mission-critical stakeholder relationships and complex data that is in a constant state of flux. From our experience, those organizations that have experienced greater value from their PNM modernization have followed a key set of eight steps:
- Providing an automated enrollment and credentialing experience by leveraging a provider portal with automated workflows to capture data in a structured manner. Display application status and reminders of any pending information to the provider.
- Creating a case for credentialing teams to track and manage applications. Set auto reminders for contract renewals and fee schedule updates.
- Integrating with external systems for auto-verification of board certifications, accreditations, medical licensure, and other information (e.g. digital interfaces to CAQH ProView Data and ProviderTrust OIG Exclusion.)
- Leveraging internal business rules and workflow engines to review and auto-approve applications.
- Using a document management system integrated into the PNM platform that allows for standardizing the contracting process with contract templates that include approved terms, red line tracking, version control and follow up phases.
- Digitizing fee schedules to provide flexibility to develop pre-built templates for different payment methodologies from fee for service to value based arrangements and automatically include them in the payment terms section in your contract.
- Selecting a PNM platform that can maximize out-of-the box capabilities to reduce implementation and maintenance costs and take advantage of app exchange products or accelerators when required functionalities are not available.
- Implementing functionality that facilitates maintaining accurate provider data such as omnichannel, phone and/or email, reminders to providers to update their information and continually compare data with other sources for audit and correction.
Contacts: Jose Quesada, Jackie Sharlow, Derek Gaasch, Thom Bales