Every health plan has trouble getting Provider Data right. It can be extremely difficult to establish and follow best practices for provider data. The number of data elements that have to be tracked and managed for a single provider is staggering. It’s arguably one of the most complex data sets that a health plan has to manage.
But provider data also has significant downstream impacts. These can include timely access for members, network adequacy measurements, claims payment, utilization management, and regulatory compliance impacts. If not managed carefully, provider data can lead to failures in the healthcare supply chain, delays in care, delays in payment, and fines imposed by regulators.
Many health plans use their core claims system as the source of truth for provider data. However, these systems are not generally custom-tailored to the needs of today’s Provider Operations teams within even the smallest health plans. They are geared toward the management of data to pay claims. And yet, it is expected that these claims systems will feed other systems downstream. These often include third-party vendors, provider directories, medical management platforms, and CRM platforms to name just a few.
These platforms also become a basis for reporting to regulators. They are used to generate data samples for timely access and network adequacy measurement.
How can a health plan improve its collection and management of provider data? Here are three critical best practices for provider data management.
#1 – Establish a Provider System of Record
First, determine which system will be your absolute source of truth for provider data. This platform will feed all downstream platforms and the rule should be that no other platform will “compete” with this system.
Most health plans end up in a situation where they have housed different kinds of provider information in different systems.
Demographic data may originate from multiple sources and be stored in one system. This is often a homegrown application built with tools like Microsoft Access.
Credentialing data may be managed in other systems. Those systems may provide some level of rudimentary workflow to track statuses and re-credentialing events.
Contract information may be stored in yet another location, perhaps even in an Excel spreadsheet. PDF copies of the contracts may be stored on a file server.
Finally, payment information tends to be stored in a claims system to support claims payment.
All of these various data sources can create pain points for reconciling data to support reporting and other uses. Which system is correct? Are the systems out of sync? In the event of a conflict, which system “wins”?
Health plans should establish a single source of truth for provider data. This system should be capable of managing the complexities of provider data. That includes provider relationships within IPAs and MSOs. The system should be configurable so that as the business evolves changes can be deployed rapidly.
The Provider System of Record should then become responsible for informing all downstream parties and platforms with accurate and up-to-date provider information. This may mean daily or weekly provider data feeds. It could also mean real-time integration via Application Programming Interfaces (APIs).
The platform should also have the ability to manage statuses for providers. You should be able to indicate when a provider is active, terminated, contracted or non-contracted, credentialed, sanctioned, and the like. These statuses can be used differently depending on the context and should therefore be configurable to meet your needs.
#2 – Validate Provider Data Regularly
Most payers have processes in place upfront to perform validation of provider data before allowing it to be entered into their claims system for use in payment, member PCP assignment, and utilization management.
However, it’s not uncommon that this data is validated initially but then never again after that. In some cases, plans may not validate data again until they go through a system migration – a rare event for most plans. But the world keeps turning – providers retire, are sanctioned, lose their licenses, change provider groups, and relocate regularly.
For plans that don’t have a routine process for validating all provider data, data starts to become stale relatively quickly. This can lead to inaccuracies in their provider directories and incorrect or inappropriate payments at a bare minimum.
Another concern in this area is ensuring that all data that is manually keyed or provided by an external source goes through an appropriate verification process before making it “live” in any system. An incorrectly entered zip code can wreak havoc on a network adequacy filing, especially if it happens to impact the only cardiologist in a rural service area.
Health plans should ensure that the Provider System of Record they’ve chosen performs key validations upfront to minimize the chance that invalid data can enter their ecosystem, to begin with. Beyond that, this information should be revalidated on at least a monthly basis to ensure that changes are identified and acted upon with appropriate timeliness.
#3 – Build In Provider Data Workflows to Enforce Processes & Data Hygiene
Simply scrubbing data on a monthly may not be enough to ensure that it stays current and accurate. Certain data issues may require research to correct. Additionally, processes like contract renewal and credential (or re-credentialing) often impact provider data as well.
Your documented processes and desktop procedures should define the data elements that are impacted by each process. Your Provider System of Record should ideally have built-in configurable workflow capabilities. This allows your Provider Operations team to manage their workload effectively. It will also provide visibility to your management team regarding the workload and the staffing requirements to maintain a reliable provider database.
The workflow tools should include a customizable definition of the processes you need to manage. It should make it easy for your staff to collect key data elements during the process. And it should include work queues and dashboards to monitor the inventory of work and identify processes that may be draining productivity so that you can identify opportunities to improve or automate the processes.
Data collection processes should likewise enforce the data rules you’ve established. When possible, the system should disallow incorrect data. It may also recommend better or more accurate versions of the data based on external repositories and sources.
Provider Data Quality is Critical for Health Plans
The reality is that, while health plans are collecting more data than ever before, provider data remains among the most complex in terms of the structure and sheer volume of information to be collected about each provider.
This challenge is not likely to get any easier. In fact, with the introduction and expansion of services and approaches like telehealth and value-based care, it has already become more complex just within the last few years. This trend will continue for the foreseeable future.
Health plans of all sizes should act now to implement these three critical best practices for provider data management. Doing so will reap significant rewards in terms of accuracy, cost reduction, and overall risk mitigation for the payer. It will also ensure that all constituents – members, providers, and staff – have the best available starting point for receiving, delivering, and coordinating care.
Maven One Provider Data Solutions
Maven One by Decipher Solutions allows health plans to rapidly deploy provider data management solutions. With a 30-day implementation window, healthcare payers can quickly identify pain points and begin to alleviate them with Maven One’s configurable and automated provider data rules engine. The built-in workflow engine allows plans to manage workload and see where incorrect data may be originating so that it can be addressed at the source.
Want to see how Maven One can help your health plan? Request a free, no-obligation, no-pressure consultation and demonstration here.