Chief operating officer and co-founder of Santech

Neeraj K. Sharma

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Empowering members with accurate and up-to-date information on the providers servicing them is vital for payers.

Provider information such as provider specialty, languages spoken, or an organization's ability to see new patients directly affects consumer access to quality care. When these or other types of information are incorrect, there are cascading effects that can impact the patient and other entities, responsible for managing and regulating benefits across the insurance products they offer.

For payers, this is a critical time to build out their provider data teams and establish an agile infrastructure. The Centers for Medicare & Medicaid Services (CMS) has stated that nearly 50% of all provider directory locations contained at least one inaccurate piece of provider data, regardless of the focus on provider directory accuracy.

These errors contribute significantly to numerous instances that impede an efficient healthcare experience, like when patients visit doctors at the wrong locations, dial phone calls on incorrect phone numbers to make an appointment, or join a health plan without realizing that their existing clinician does not participate in the network.



Major outcomes of inaccurate provider data



As a result of inaccuracies, these situations directly impact patient satisfaction and trust.

Payers must manage and enhance provider data quality to avoid member dissatisfaction or ultimately losing them. Besides, poorly managed provider directories can cause delays in reimbursement, increased administrative costs, or frustration for payers, providers, and networks.

Some of the areas of noted data inaccuracies are providers listed at the wrong location, incorrect phone numbers, providers not accepting new patients when the directory indicated they were, wrong suites, and incorrect specialties.

Additionally, provider data changes at a rate of 2 to 2.5% every month, which means that payers need to stay on top of their business.

Below are five sure-fire tips for payers to build provider networks with speed, data quality, and compliance.





Ensuring that different teams within payer’s staff are working off the same playbook of Provider information is a continuous challenge for health insurers but ultimately serves as a key to success.

Currently, multiple teams build their own provider data silos, and that information is subsequently updated by different stakeholders in different systems.
In recent years, the scrutiny around this data has increased due to compliance issues, so now if an insurer has a single source of truth, an update can apply in one place and that system will supply the data to other sources, removing the room for error.
Besides enforcing provider data quality, working off a singular information set rather than multiple touchpoints can help improve compliance and strengthen relationships with providers and patients.





Much like establishing a single source of truth, payers need to be wary of multiple systems inputting data simultaneously. Health plans need to take the task upon themselves of filtering through the available information to assess bad, incomplete, or inaccurate information during data loads.

The complicating factor in this equation is that payers often don't have the existing infrastructure to conduct this constant monitoring, which is far from a manual task.
Payers should be performing aggregate-based validations and verifications of subject areas, to proactively identify data issues. This can be accomplished through continuous source-to-source verification (both internal and external systems), data-issue tracking, and efficient workflow management to help validate provider data immediately.
If not, bad data can serve as the basis for incorrect strategies and decisions related to network expansion and other changes. Downstream, this inevitably results in pending claims as well as unhappy providers and consumers discovering a provider doesn't meet their needs at all.



3.) Conduct Continuous data quality checks



Payers have a hugely important task on this front: find out what important data set is missing or changing. Given the network size and number of changes coming from providers in varied forms, this cannot be achieved manually and can only be accomplished if payers have the appropriate system in place, which keeps them up to speed with changes rather than playing catch-up.

An efficient network management system keeps an eye on every critical part of provider information and ensures the change follows its designated lifecycle for completion before getting passed on to the claims, directory, or care management system.
The problem is that most payers are not conducting these data quality checks as it requires significant human efforts and is only doing so on an either ad hoc basis or an as-needed basis. That must change.

Health plans would benefit from conducting monthly data quality checks to ensure the accuracy, relevancy, completeness, and timeliness of provider data.





As healthcare pivots from the worst of the COVID-19 pandemic, there are substantial opportunities to repair the relationship between payers and providers. Collaborating to improve the communication and dissemination of provider data is one such area of mutual concern.

Through an accessible online portal, providers can update their information and give payers a reliable dataset for their operations. There should also be a consideration for establishing a practice administrator portal where practice administrators can update their provider records as well.



5.) Embrace CMS Mandated Provider Directory APIs



This is an even more important consideration in light of CMS' decision this summer to begin enforcement of requirements for certain payers to support Patient Access and Provider Directory APIs. Instead of looking at this situation as a compliance issue, payers should view it as an opportunity to work better with providers in an effort that data points are accurate. For years, both sides have sought common ground and now this regulatory obstacle can serve as the building ground for one.

Payers should employ provider network management infrastructure which is ready with API toolkits for providers to submit directory changes, seek confirmation through APIs. Agile network management equipped with API gateway configurations, can launch, monitor, and scale this operation.

Additionally, payers should try to use this opportunity to go over and beyond the CMS mandated requirements for APIs and allow larger groups to submit new provider enrollment, re-credentialing information, and directory attestation through APIs to build an edge for their business.




Employing an agile provider network management solution can enhance data management capabilities that can help build better relations with providers and better networks in record time.

A payer's agility comes from how quickly they know that the source is capable of taking data, matching the data, cleaning the data, and applying necessary updates. An intelligent dataset supports the ability of all stakeholders to access and update data.
The current process for payers to launch a new network is too slow and involves going through so many manual steps. Breaking that cycle and moving towards network management that values low costs and improved outcomes is an ideal endpoint in the modern healthcare landscape.

It's clear that the fast-paced business environment, combined with human error, bears inaccurate and fragmented provider data for payers. Because of this dynamic, health plans must be vigilant about constantly updating provider data points for best practice.

Payers currently get provider data from many sources, comprising provider group rosters, claims, as well as credentialing and contracting processes. Unfortunately, no one source contains the complete truth. Hence, it's vital to identify the authenticity of sources, the friction between them, and which sources are most reliable for which data elements.

It's a worthwhile endeavor to pursue a diversified approach to provider data management, including cross-industry touchpoints, referential data, and claims analytics. Businesses that consider data as an asset and optimize their data management capabilities will be more insightful and offer quality care to their consumers.

Emphasizing a singular, data-driven truth can eliminate inaccurate provider data that leaves enormous gaps in an organization's ability to render quality care to patients. Data is central to all health plan processes and needs to be always kept top of mind to ensure a strong foundation with which to work.

Embracing these best practices of provider data management quality has the potential to correctly enforce provider data quality across the enterprise, boost productivity, compliance, and improve the patient experience.

Articles

Provider information such as provider specialty, languages spoken, or an organization's ability to see new patients directly affects consumer access to quality care. When these or other types of information are incorrect, there are cascading effects that can impact the patient and other entities, responsible for managing and regulating benefits across the insurance products they offer.

Embracing an Agile Network: 5 Tips to Build Provider Networks with Speed, Data Quality and Compliance 

As payers and providers seek to uncover collaborative opportunities in an industry increasingly shifting toward value-based healthcare, it's critical to identify and eliminate barriers to improved partnerships.

The challenges to mutually beneficial payer–provider partnerships vary, but many of them are rooted in an outdated way of managing provider networks. For example, data is segmented into separate departments, multiple systems are used for different network management functions, and networks are siloed into different systems.

The result is a haphazard patchwork of network management policies and processes that make it hard to create agile provider onboarding and maintenance to deliver flexible, affordable, and quality networks in demand today.

Current status of provider network management

The administrative costs of closing data gaps between payers and providers due to inefficient processes and inaccurate data total nearly $300 billion annually, accounting for about 15% of all healthcare expenditures, according to a 

 on healthcare's adoption of electronic transactions.

It is primarily due to inefficiencies in provider onboarding and maintenance, which payers can mitigate with the help of an agile provider network management infrastructure.

Payers often use several disjointed, homegrown, or vendor-procured point solutions to manage their provider networks. However, these systems lack efficient provider communications and automated workflow management with limited ability to facilitate electronic data submission.

In one example with far-reaching implications, the inadequate “provider match and cleanse” capability in such systems frequently results in duplicate provider information, wrong locations, or wrongly marked specialties. This erroneous data becomes the basis for strategies and decisions related to network expansion and other changes. Moreover, it inevitably results in dissatisfied members recognizing a provider doesn't meet their needs at all.

Networks are also siloed off into different systems and locations across the enterprise due to the lack of a centralized network management system, preventing the ability to rapidly create new networks based on existing ones.

These issues have a corrosive effect on cost, efficiency, and relationships with providers enrolled in the network. The overall friction results in involuntary network dropouts or unattested records, contributing to increased costs for payers.

Compounding the problem is that most of these processes are manual and inefficient rather than integrated and agile. It creates a friction point on both sides by diminishing trust while increasing administrative burdens and reimbursement delays.

Creating a successful payer-provider relationship depends on integrating existing systems with a tool for visibility, agility, and engagement to establish and maintain trust. In addition, to shifting towards agile narrow networks and value-based care, payers can focus on creating alignment in several key areas:

Connecting with internal and external data resources.

Payers should invest in technologies that seamlessly interact with internal and external data resources, enable bulk data uploads and extracts, and examine network data to align with a network strategy of strengthening provider partnerships.

Tools like self-service portals allow both payers and providers to access complete, actionable data, reducing administrative burdens for both parties.

 Payers should distribute their network data to their downstream systems; it improves integration to downstream systems that rely on accurate and timely network data (i.e., claims system, provider directories, Provider Portals, and data warehouses).

Alignment through integrated agile provider network management solutions

Employing an enterprise-wide provider network management solution is one of the best ways payer organizations can address the provider data management problem. Payers can use provider network management solutions to reduce unnecessary costs and inefficiencies while improving provider and member satisfaction.

 solution should have the following features:

Use provider data as an enterprise asset by allowing all stakeholders to view, update, and leverage activities like recruitment, credentialing, contracting, claims, and care management.

Capability to onboard providers by seamlessly fetching provider data from industry sources (e.g.: - NPPES, CAQH, LexisNexis, Quest Analytics) to expedite provider onboarding and maintaining consistent data set.

Inclusivity by allowing providers and their practice administrators to come online and review their records along with administrative control to approve change requests made by external stakeholders.

Deployment of intelligent algorithms to match, cleanse, and standardize providers to avoid duplicates and error-prone records.

Payers can experience several benefits by incorporating these features that include a more effortless experience building a network, reduced time-to-market, and improved network monitoring with real-time analytics.

For payers to create the product that wins more members quickly, efficiently, and cost-effectively, they need to address the underlying issues of organizational siloes, manual processes, and legacy systems. Mitigating the problems will make it easier for providers to exchange quality information and improve provider data management systems by allowing providers to engage, participate, and keep themselves updated in the health plan system.

With timely access to accurate network data, payers can better manage costs, improve engagement with providers, and ensure their members have the information they need to make informed healthcare decisions

is chief operating officer and co-founder of Santéch, a healthcare technology company that offers provider-network services.

If payers have timely access to accurate network data, they can manage costs, improve engagement with providers and help members make healthcare choices.

Neeraj K. Sharma

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