Today’s payers are still adjusting to the significant operational and transparency changes as a result of the No Surprises Act and Consolidated Appropriations Act. These mandates put the provider network operation on the front line and at the eye of the storm of some pressing market conditions—from the regulations to escalating, costly labor challenges and damaging provider abrasions that can easily build to member abrasions. The inherent network database inaccuracies shouldn’t be underestimated as just operational and physician satisfaction bottlenecks. These discrepancies can prevent patients from accessing the care they need, leading to poor health outcomes and satisfaction levels. Additionally, the spotlight is now even brighter with recent No Surprises regulations requiring providers and payers to keep patients informed about the costs of care and their personal financial responsibility throughout the care journey.
The race to respond is on and health plans are now completely rethinking the fulcrum point of provider network operations so they are both strategic and sustainable. To help address this need and fortify a reliable provider network, many health plans seek provider network management tools to facilitate provider data operations that will improve accuracy for enhanced provider and member experience while delivering significant cost savings.
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Provider network teams need a better way to streamline healthcare delivery and amplify provider satisfaction. Unlocking value with provider network operations means a forward-looking, fresh approach and the right tools that deliver in four essential areas:
1. Resolve breakdowns and bridge gaps with one platform
Provider network operations is no stranger to today’s labor challenges. This area is rife with employee burnout resulting in repetitive and unrequired administrative processes. Many provider data inaccuracies stem from inefficient, error-prone back-office operations supported by disparate and disorganized systems. Technology that offers a seamless, end-to-end system transforms provider data management for enhanced provider experience, accuracy, compliance, and plan performance. The right platform will be scalable and flexible—consolidating various network management features into one platform. As a single source of truth, built-in analytics can access the vast universe of provider network data and an optimized system will go one step further—to proactively provide suggestions to amend or modify a health plan’s network. This tool can bridge that sometimes steep payer-provider gap, with omni-channel communication features that sit on top of this platform for seamless and frictionless dialogue.
2. Deliver better journey navigation and experience with digital
Simple fact: there is no way to provide an optimized customer journey without digital. Today’s healthcare customer expects cost-effective, quality healthcare. Members searching for providers will most likely encounter frustrations and stress. After all, this is probably one of the most important buying decisions they will make. This search is made easier and less confusing with an Amazon-level concierge experience, bolstered by a direct and fast path to provider selection. Provider data is best supported with digital solutions that can work together in a unified and real-time way to address interconnected pain points—ultimately aiming to:
- Improve member experiences and address the entire journey.
- Enhance flow of information and visibility through better data access.
- Introduce self-service portals that assist with information gathering.
- Simplify the overall healthcare experience journey, with more effective and efficient automation.
At ViVE 2024, Panelists Share Prior Authorization Progress and Frustration in Payer Insights Program
At the Payer Insights sessions on Day 1 of ViVE 2024, a panel on prior authorization offered compelling insights from speakers who shared the positive developments in this area after years of mounting frustration. Speakers also shared challenges as they work with providers to figure out how policy developments and technology will work in practice.
From the digital front door to back-office efficiencies—provider network tools can’t be underestimated for addressing many touchpoints, to satisfy two of health plans’ key stakeholder groups: both members and providers.
3. Ensure interoperability in your chosen model
Don’t make the mistake of investing in technology without built-in integrations and APIs to the data sources used for provider data validation. Without seamless integration, data is siloed and lacking optimized verification to complete the providers’ onboarding, credentialing, and contracting experience. With interoperable technology, payer directories are updated seamlessly, with data available in a format to ease health data exchange between providers and improve public health reporting, a need highlighted by the Covid-19 pandemic.
4. Improve your provider relationship management and reduce abrasion
The adage of “you can’t manage what you can’t measure” is taken one step further here—for “measure and share.” Poor provider data management is a key cause of abrasion. Frustration can even extend to members/patients, resulting in lower quality ratings and even disenrollment. Enter data sharing as one key component of payer-provider collaboration. To create a value-based care model, detailed data sharing decreases administrative costs such as unnecessary correspondences requesting missing information or supporting documents that lead to provider fatigue. With the right platform, providers can submit applications electronically to streamline communications and reduce administrative burden. Additionally, providers can keep directories updated with a portal feature to help health plans avoid penalties. With the right provider network tool, plans and providers can work together and coordinate a win-win-win, for payer, provider, and member-patient.
The future is here
In all these areas, outside consultants have the solutions, designed with the optimal mix of digital experience tools and experience acumen, to open up avenues of more innovative provider data management. These partners can provide end-to-end impact with high-value solutions that can affect downstream processes such as claims adjudication and member calls. With a coordinated approach to provider data, ROI can be significant. Value-based care tools bridge key payer-provider gaps, seizing opportunity to resolve lack of data standards and fragmentation—for a more collaborative focus on members/patients, and improved outcomes for all.
Photo: atibodyphoto, Getty Images
Lohit Thammanna, Manager Operations and Practice, leads Provider Network Operations (PNO) and Practice for Sagility. He has more than 13 years of experience at Sagility steering customer experience success for healthcare organizations by upscaling traditional business models into efficient operations and increasing profitability across the value chain. He has a sound grasp of the Provider Data Management, Contract Configuration, Credentialing and Re-credentialing.
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