If payers have timely access to accurate network data, they can manage costs, improve engagement with providers and help members make healthcare choices.
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The challenges to mutually beneficial payer–provider partnerships vary, but many of them are rooted in an outdated way of managing provider networks.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.
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 CAQH Index report 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:
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.
An agile enterprise-wide solution should have the following features:
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
Neeraj K. Sharma is chief operating officer and co-founder of Santéch, a healthcare technology company that offers provider-network services.