For decades, health insurance payors have relied on outdated legacy workflows, antiquated provider data management systems, manual data entry and internal departmental structures. All of this disjointed approach results in errors in provider data for payors. These challenges can occur at many points during the provider’s tenure with a payor including during the onboarding process; credentialing and re-credentialing; contracting phase or even updates such as address changes or patient panel openings.
This “too many cooks in the kitchen” approach leads to a lack of standardization resulting in additional data inaccuracies, claims denials, increased administrative overhead, regulatory challenges and heightened business risks. The problem is significant and wide-spread, and according to JAMA Network, 81% of payor directories had entries that were inaccurate across five major payors. And it is all at a cost: inaccurate provider data is estimated to cost the healthcare industry $3 billion annually.
Inefficiencies and Errors Affect Providers and Patients
These prevalent and costly errors cause frustration for providers and can also impact patient care. New providers in payor networks can spend countless hours trying to get their information to the correct department. Even for existing in-network providers who have a change, e.g. a new office location, it can be a time consuming and frustrating process. Patients who are faced with inaccurate provider directory information, e.g. a provider with a closed patient panel who is listed as accepting patients, may lead to delays in the patient seeking care. And disruptions and delays in necessary care are very serious: They can lead to higher early mortality.
Advantages of Automating Data with PDM Platforms
Faced with these costly inefficiencies, payors are coming to terms with the need to standardize processes, integrate systems and improve efficiencies within their provider networks. There is a growing need for integrated technology platforms like Santéch’s I-Network that can help payors transcend legacy processes and departmental silos that have plagued provider onboarding and maintenance processes for decades.
Here’s a look at the advantages and benefits that integrated provider data management (PDM) platforms offer:
- Streamlining Provider Onboarding
By automating credentialing and verification, providers can start the onboarding process and document uploads, which expedites the recruitment and information collection of new providers. They do this through pre-built API integrations with external provider databases like NPDB, Certified Verification Organizations (CVOs) and third-party credentialing agencies like CAQH. Payors can find network gaps, review available providers in the area and prioritize the network expansion efforts.
- Simplifying and Automating Contracting Process
I-Network simplifies the contracting process by automating file reviews, primary source verification, real-time validations and faster credentialing. The automation built with Artificial Intelligence can help payors use the right template for the contracting process based on geography, specialty and network selection of the provider group there by reducing errors, necessary re-works and delays during the contracting process.
- Expediting the Credentialing and Re-Credentialing Process
This integration allows automated file reviews, primary source verification, real-time validations and faster credentialing. During the credentialing process for example, payors can also use the platform to reach out to providers to request missing information to track privileging status, such as certifications, specializations and procedure privileges. The workflow for verification allows payors to seamlessly leverage an internal or an external CVO. Later, the PDM platform can generate alert reminders for reenrollments and recredentialling.
- Reducing Administrative Burden for Providers
The platform then allows providers to upload and update their information in a single interface. They—and their administrative staff—are saved from having multiple points of contact in multiple departments. The platform provides intuitive workflows for achieving complex transactions such as practice buy out (Tax ID changes), location changes, moves and closures through a few simple clicks. More accuracy in the data allows for fewer errors with reimbursement and directory listings.
- Providing Accuracy for Patients
With the availability of correct and accurate data in the payor provider directory, members can find and reach the right in-network provider, reducing frustration and increasing patient satisfaction. It also allows patients continuity in care, fewer issues with inaccurate provider billing and more opportunities to easily find providers who are in-network and accepting patients.
- Improving Compliance
And finally, PDM platforms allow payors the ability to track the status of provider onboarding applications, contracts, reimbursements and compliance with network adequacy requirements. By offering visibility into contract expiration dates, audit trails and network adequacy benchmarks, these platforms help payors continuously improve the way they manage their provider data within their networks.
Integrated provider data platforms like I-Network are designed to optimize efficiency, accuracy and transparency throughout the provider data information journey. As the provider and payor ecosystems continue to digitally transform, such platforms will play an increasingly pivotal role in keeping provider data accurate, up-to-date and compliant.
About Neeraj K. Sharma
Neeraj is a healthcare technology leader with over 25 years of experience in simplifying Healthcare IT for payors, networks and healthcare organizations. As President & CEO of Santéch, Neeraj focuses on building simple, scalable solutions that enable transformation in network and provider management. Prior to Santéch, Neeraj successfully established and managed healthcare solutions and consulting practices at global IT consulting firms like 3i Infotech, HCL, and TCS.
About David Van Houtte
David is the Chief Growth Officer at Santech, bringing 25 years of extensive experience in healthcare. Previously, he served as Vice President of Network at a top five payer, where he led provider network and value-based strategies. At Santech, David has a passion for improving provider data accuracy and creating operational efficiencies through improved provider/physician onboarding workflows. He is responsible for implementing our go to market strategy with both Payor and Provider organizations and promoting our innovative Provider Data Management solutions I-Network and I-Enroll. David holds a Master of Public Administration degree in Health Policy and Management from Seton Hall University, loves sailing and outdoor activities such as spartan racing.
