Provider Network Management

Increase efficiency and savings with provider network management solutions

Team Innovaccer
Thu 05 August 2021
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To improve health outcomes, payer organizations need to organize, maintain, and effectively use provider data to enhance care management and delivery—and effectively comply with ongoing healthcare regulations. Mandates such as the Patient Protection and Affordable Care Act [PPACA] are driving payer organizations to build and implement more efficient provider network systems.

Enter: provider network management solutions. These solutions provide actionable insights that help payer organizations manage provider networks effectively and accurately, leading to improved benefit coverage, higher member and provider satisfactions levels, and reduced operating costs.

Challenges for payers

Maintaining accurate provider information requires continuous updates—and even then, can prove tricky. A 2016 study showed that each year, 20% of physicians change their address and/or phone number and 30% change their health plan, hospital, or group affiliations. And according to a 2016 study by the Centers for Medicare & Medicaid Services (CMS), the average inaccuracy rate by location for the 54 organizations researched was 41.37%.

COVID is expected to increase the amount of healthcare mergers, so maintaining accurate data is becoming more critical than ever. By the time an update is transmitted, processed on the payer's end, and applied to the correct profiles, it could already be outdated

According to conservative estimates, the commercial healthcare industry spends at least $2.1 billion annually on maintaining provider databases. Without high-quality provider data, stakeholders face significant challenges, including:

  • Inaccurate cost predictability
  • Irregular provider contract management
  • Implementing constantly evolving regulations
  • Inconsistent, poor-quality data, leading to data inaccuracies
  • Provider recruitment, credentialing, and site inspections
  • Inaccurate claims processing and payment authorization
  • Over- or underpayment of reimbursements
  • Complex appeals processes

A lack of data integration and management also decreases a payer’s ability to differentiate itself in the marketplace through quality services and high provider and member satisfaction. Provider data integrity lapses make it difficult to improve overall performance, reduce errors, or cut down costs.

Additionally, health plans can struggle to engage with providers. Office staff usually have other responsibilities and often don’t prioritize maintaining and updating health information. It can also be challenging to get providers to comply with rules or send updated information. States put different limitations on how often payers can reach providers, so even tasks such as simple reminders are easier said than done. That means collecting and disseminating more information with fewer touchpoints.

Not having the correct data is costly for both payers and providers. Poor provider data management can lead to inaccurate directories and leave patients dissatisfied. Providers can lose revenue when appointments are missed, and payers may face large fines: up to $25,000 per Medicare beneficiary for errors in Medicare Advantage plan directories and up to $100 per beneficiary for mistakes in plans sold on the PPACA exchanges.

A report by CMS found that 45.1% of provider directory locations listed in online directories were inaccurate. Medicare Advantage members rely on provider directories to locate in-network providers, so having accurate directories is critical to making care accessible. Physicians who are engaged with their hospitals and collaborate with their care teams are 26% more productive than their less engaged counterparts.

Provider network management: The Innovaccer solution

With an effective provider network management tool, payer organizations can efficiently receive, organize, manage, and utilize data from their network of providers. They can also gather more insights than with conventional analytical tools. Provider network management helps foster consistent care delivery, leveraging data to identify high-risk providers and ensure health insurance coverage for patients. It can also help payers increase their ability to apply new network policies and cooperate with providers to successfully distribute new products, payment approaches, and care delivery models like value-based care. Network management helps payers implement and effectively administer pay-for-performance programs to reimburse providers based on the quality of care. Payer clients that have built or purchased consolidated provider contracting, credentialing, and data-loading platforms report lower IT maintenance costs, faster provider onboarding, and improved provider directory accuracy.

Innovaccer's Provider Network Management solution helps payers build and manage high-performing provider networks using a holistic, coordinated approach that boosts cost savings and efficiency.

Innovaccer's solution is an end-to-end management solution that helps payers with:

  1. Strong, accurate provider data (including credentialing, directory, and contracting data) and an analytics foundation
  2. A command center to drive provider engagement, performance, and vendor management
  3. Provider-facing workflows to manage risk, quality, referrals, and prior authorization and reduce the cost of medical record retrieval

The road ahead

With increased focus on improving the quality of healthcare via regulations and mandates, it’s imperative for payer organizations to implement a robust provider network management tool. This added focus also means that payer organizations need to adapt their core strategies and look for solutions which can assist in regulatory compliance, collect and manage provider data accurately, drive down administrative costs, and—ultimately—improve satisfaction and health outcomes.

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