For consumers and injured workers, navigating and accessing health care can be a challenging journey.  It begins with selecting the best route to the best providers among multiple providers, sites of care, and types of healthcare services. This can lead to confusion and dissatisfaction, delays in getting care, network leakage, unaffordable treatment, and higher costs overall. Health Plans and Workers’ Compensation organizations are in a unique position to ensure a smooth care navigation journey by taking a holistic approach to provider data management.
 
A provider data management program designed with care navigation in mind can orchestrate a better experience, lead to more intelligent healthcare decisions, help curb healthcare costs, and ensure access to high-value primary and specialty care.

by April Stiles... 

​Health plans, providers, and workers’ compensation organizations have increasingly seen that supporting consumers, patients, and injured workers in a more holistic way can make a significant difference in the health and wellbeing of both the individual and the overall population. To be successful, it is important to find ways in which to reduce the burden caused by the social determinants of health (SDoH).
 
Addressing social determinants of health is a critical to achieving health equity. Although, it can’t address all the challenges related to SDoH, provider data management can play an important role by promoting network integrity and offering critical user insights to support decision-making.

by April Stiles... 

​Understanding family history and genetics are important factors in assessing and predicting health, however there are other factors that have been shown to have an even greater influence. According to a study published in the New England Journal of Medicine, “60% of a patient’s healthcare outcome is driven by their behavior and social and economic factors, 10% by their clinical care, and 30% by their genetics.” (1)
 
Geography matters.
 
Multiple studies demonstrate that there are large disparities in health status among specific races and ethnic groups, and socioeconomic classes which closely align with where they live. The physical features and social patterns of specific neighborhoods have been shown to impact health outcomes. Air and water quality, climate, housing, crime rate, and the existence of recreation areas all contribute to life expectancy.
 
Zip codes are becoming important indicators. A 2011 study reported that “Life expectancy gaps of up to 25 years have also been identified between different neighborhoods within the same city.” (2) Given this evidence, 5-digit zip codes may not be enough. The zip +4 codes are more precise as they narrow geography down to the radius of a few blocks or specific smaller areas.
 
Ensuring accessibility can result in better outcomes for members and injured workers. This is where provide network management can play a role. Capturing provider zip codes beyond 5-digits can help in ensuring geographic coverage of a provider network or provider panels.

A beautiful user interface in a provider directory is the right idea, but only if the data it contains and presents is reliable, error free, up-to-date, quickly accessed, compliant, and intuitive. A focus on the “important stuff” can improve NCQA scores, ensure compliance, build member loyalty, and reduce the workload burden for health plan teams. 

By outsourcing and optimizing the back-end process of provider data management, organizations can better streamline workflow and better manage the  “stuff” that contributes to staff burnout and burden. Conflicting data formats and platforms, duplication of effort, lack of accountability, data siloes, and other inefficiencies are eliminated by an automated infrastructure that continuously maintains network integrity.
 
Modernizing the backend of provider network systems and processes helps to accelerate digital transformation and reduce the hidden cost related to staff burnout and attrition. It starts by assessing the current state of provider network data sources, data integrity, internal and external resources, and overall efficiency.  This helps identify the true cost of inefficiency, data errors, and burnout. 

A reimagining can help to reduce workflow steps, increase accountability, enable access to authoritative data, automate data sourcing and cleansing, and finding a more efficient roster management process. Re-engineering operational strategies and processes, unburdens stakeholders across the organization. Internal teams can better focus on other critical aspects of the business.

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The impact of unnecessary or redundant administrative processes related to provider network integrity creates a snowball effect that is shared across the entire health plan organization. This incurs decreased revenue and increased expense line items within departments such as IT, network management, claims management, risk adjustment, and more.  For example, a mid-sized health plan with 3 million members could potentially be at risk for more than $100M in lost revenue and compliance penalties—in a single plan year, according to a study by HealthScape Advisors.

Underlying issues related to staff burnout and turnover contribute to the snowball effect as more burden is placed on team members, when their colleagues resign. This opens the door to errors, more inefficiencies, and more resignations which contribute to a higher cost of doing business.  Health plans and Workers’ Compensation organizations can no longer accept this as the “normal cost of doing business.” Keeping on the same path makes maintaining provider network integrity virtually impossible and increasingly costly.

Organizations must determine what role their current provider network management processes may be impacting the burden on staff. They need to take a brutal look at how inefficiencies in back-office operations impact both the visible and hidden costs of maintaining provider network integrity. Only in doing so, can they identify opportunities for automation and outsourcing that can contribute to help to improve member loyalty and satisfaction, lower costs related to risk and inefficiencies, and lead to less burden and greater work-life balance for their teams.

Learn more in this FREE eBook.

According to the US Bureau of Labor Statistics, the number of U.S. workers who quit their jobs in 2021, was 47.8 million. The employee attrition continues, as March of 2022 saw a record 4.53 million workers leave their jobs in what is being called “The Great Resignation.” The impetus of “The Great Resignation” is driven by employees rethinking what work means to them, how they are valued, and how they spend their time. Salary and burnout from lack of work-life balance are at the top of the list of reasons for workers to change careers, employers, or leave the workforce altogether. The healthcare industry is one of the hardest hit.

This year alone (2022), nearly 1.7 million people have quit their healthcare jobs—equivalent to almost 3% of the healthcare workforce each month. 

The 2022 National Burnout Benchmarking report from the AMA found that with 37% of physician respondents said they intended to leave their organization within the next two years. This may be a message in a bottle for provider network teams indicating that it  is time to reimagine provider data management. These changes in provider affiliations and demographics will have a domino effect, increasing the burden to health plans when it comes to keeping up with the revolving door of changes to provider data networks.

Provider network and claims management teams alike are experiencing burnout and dissatisfaction that must be addressed if health plan and workers' compensation organizations are to promote network integrity. Organizations are facing the growing challenge of retaining their teams across the organization, while finding it equally challenging to replace the roles that are being vacated. 

If we reimagine provider data and network management, we can eliminate burnout.

​Learn more in this FREE eBook.

by Howard Koenig...  

​Provider data management faces growing challenges in the age of digital transformation at a pace that may be difficult for organizations to match. Current data management processes and analytics capabilities may serve as a roadblock to its evolution.
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A 2016 McKinsey Survey points to data management as the primary challenge for organization, finding that “86 percent of executives say their organizations have been at best only somewhat effective at meeting the primary objective of their data and analytics programs, including more than one-quarter who say they’ve been ineffective.” *

by Howard Koenig...   
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To blaze the trail for digital transformation, provider data management requires a transformative approach and technological innovation. What differentiates this approach and defines innovation is the data itself and how it is used. The architectonics of provider data need to be scalable, designed to anticipate change, consumable from many formats and attributes, and discoverable in a valuable way for both business and consumer users.

The role of machine learning (ML) and artificial intelligence (AI)

by Howard Koenig...
It is important to break down data silos to access and transform data that is complete, usable, and standardized to apply advanced analytics to enable more informed decision-making for all stakeholders within the provider network enterprise. The biggest challenge is keeping provider data accessible, secure, and relevant, as it must be managed across multiple clouds, external and internal entities, platforms, applications, and attributes.

By April Stiles... 

For Workers’ Compensation companies, providing immediate access to accurate and quality provider data is a critical step to get injured workers back to work quickly. By establishing an intuitive process to manage provider data, organizations can easily assist injured workers in locating quality providers on site, online or via mobile access so that they can seek medical treatment as soon as possible.
   
It is important to empower claims professionals and case managers with the digital solutions they need to optimize workflow, assist injured workers, and control medical claims costs.
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Here are eight solutions that can help organizations get injured workers back to work quickly.  

Provider data is a critical revenue generating asset for health plans, health systems, and workers compensation organizations. Roster management is an essential process for ensuring provider data accuracy. Roster management enables organizations to associate or disassociate a provider with whom they are currently affiliated with or in the process of contracting, to include within their provider data management ecosystem.

The impact of inaccurate data includes:

• Negative consumer experience
• Bad press within the market
• Provider abrasion
• Undue administrative burden
• Fines or sanctions by regulatory organizations​

Medicare Advantage insurer Zing Health has chosen Perspecta LLC, an innovator in provider data management solutions,  to make its provider directory more accurate and reliable using artificial intelligence and machine learning.  

Zing Health’s advanced approach to health data aims to improve care access and quality for under-resourced populations. Perspecta’s Roster Management 3.0 solution applies machine learning techniques to intuitively distill Zing Health provider data from hundreds of doctors, clinics, and hospitals into an accurate, uniform format. Perspecta’s process employs both digital algorithms and programmatic verification to confirm hospital affiliations, medical specialties, locations, and other essential information; thus automating a previously cumbersome manual process and freeing up valuable IT resources to focus their attention elsewhere. 

by April Stiles... 
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Provider directories are often riddled with inaccuracies, burdening everyone who attempts to access this crucial data. Whether it is patients, providers, or healthcare personnel, errors in provider data prove to be a major roadblock for everyone in ensuring network accuracy and adequacy.

A 2016 study by a research group at West Virginia University tested California health insurance directories, posing as patients and attempted to make appointments with 743 primary care physicians listed in California health plan directories. These “secret shoppers” were unsuccessful 70% of the time. *
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by April Stiles...   

Attempting to traverse through the ever-changing, quagmire of provider data can be a resource-intensive, tiresome task. As it is a crucial aspect of the health plan and workers compensation internal operations, it is imperative that provider data be managed efficiently so as not to burden those who rely on its accuracy, such as internal and external stakeholders, regulators, and consumers. 

by Joseph Kennedy... 

The No Surprises Act was signed into law on December 27, 2020 as part of the Consolidated Appropriations Act of 2021 (H.R. 133; Division BB – Private Health Insurance and Public Health Provisions). The No Surprises Act addresses “surprise” medical billing at the federal level. Out-of-network billing, or “surprise medical bills” are usually the balance between what the individual’s insurer pays for the out-of-network care and what the provider charges for the services.

Simply put, the act states that patients should not be responsible for out-of-network costs they did not agree to pay.
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The Departments of Health and Human Services, Treasury, and Labor will be releasing regulations and guidelines for the implementation of these provisions before the largest sections of the legislation go into effect on January 1, 2022.

by Sean Healy...   
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Provider referrals management is a strategic balance of getting the best clinical outcomes while controlling overall claims cost. This starts by creating and managing a high-functioning provider and partner referral network to ensure beneficiaries and members receive the best in-network care when and where they need it.

Ensure a high-performing referral network
Referral networks should be measured on clinical outcomes, ancillary utilization, and proximity to the beneficiary or member. High-quality providers offer the lowest-cost and appropriate, high quality care. As such, claims adjusters and case managers need a way to quickly identify providers that match the beneficiary’s coverage plan to find the best specialists and ancillary providers that offer accessible appointments and locations.

Enable provider & partner referral insights
Data and analytics help to optimize referrals management by continuously assessing the referral network. Analytics data can provide claims managers and care managers with clear insights into why and when beneficiaries should be referred to a particular provider and which partner offers the most efficient and cost-effective service. Prioritization should consider price, location, rating, and outcomes to control costs while improving outcomes and satisfaction.
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In addition, an intuitive referral management solution can help an organization monitor the time it takes for beneficiaries or patients to obtain an appointment or if there has been a change in the provider practice in order to expand its preferred provider network as demand increases.

Continuously check & update provider information
Accurate provider data is critical in referral management. Inaccuracies are the biggest barrier to care and contribute to higher claims costs and risk. It is essential to know if a provider moves from in-network to out of network, has moved, is no longer accepting patients, has an incorrect phone number or address before making a referral.
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High performing referral networks maintain access to a centralized repository of provider data to ensure referrals to the right provider. A master provider database should be designed to check, cleanse, and manage complex, dynamic data.

Centralize referral resources
With a provider network varying in specialty, geography, and quality, it is important to keep resources consolidated and centralized in an automated, digital referrals management system. A comprehensive solution should integrate claims systems and provider directory information. Intuitive referral management solutions can even prepopulate provider and claims data to simply the workflow for claims adjusters and case managers.
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A high-performing provider referral process should eliminate time-consuming administrative tasks and processes to foster better consumer and beneficiary experience and reduce the cost of care.

Learn more by checking out Perspecta's provider referral management solution.

by April Stiles...  

Navigating in the sea of disparate provider data is a tumultuous, tedious, & resource reliant endeavor. With data existing in conflicting formats & fragmented attributes, & across various applications across your organization & partners, how do you efficiently transform, cleanse, standardized, & reconcile provider data? For many healthcare organizations, provider data cleansing is like commanding a paper boat at the price of a luxury cruise ship.

The variations in formats, exchange, content, & intended use create a tsunami of costs related to internal resources, time-consuming workflows, & regulatory fines. This poses unnecessary obstacles for consumers. providers, health plans, & partners who need access to reliable provider information.

So how do you chart a better course?

Benchmark data accuracy.
Before starting your data cleansing voyage, it is important to benchmark the current state of your provider information. Begin by creating a data repository that collects & maps data elements. Use a smart analytics solution that can identify and score your provider network data to pinpoint inconsistencies, duplicates, and errors.

Find an expert provider data profiler.
With no industry-standard format requirement, provider data discrepancy detection becomes difficult. An AI-enabled data profiling process can automate the identification of metadata & provide visibility & data matching right down to the single attribute level. Artificial Intelligence helps to pinpoint inconsistencies to assure comprehensive data cleansing. It optimizes the cleansing process by mapping data from source to transformation & finally to destination using commonly used formats​

Check. Cleanse. Check again.
Your cleansing workflow should include quality checks of the information flow to monitor and correct errors that may occur during processing. Data integrity can be ensured with AI-powered data transformation, scrubbing, validation, and transport. A final check and scoring of your data help you establish a higher benchmark for accuracy moving forward.

Don't go it alone.
Provider data is a critical part of your business, so it is important to find a partner that really knows the industry to control costs and manage the challenges you face. A trusted provider data expert can more efficiently and effectively take on the workload, helping you reduce costs and free up internal resources to focus on other areas of your business.

The goal is to reduce costs by automating workflow to continuously clean enterprise data that can be accessed for consumer searches, integration, reporting, and analyses across your organization and regulatory environment. 

by April Stiles...   
The value of accurate & compliant provider network data cannot be overstated. Provider Directories serve as road maps to help consumers and their families decide which health plan to enroll in or how to access the best care for their needs. According to a 2013 Health Reform Monitoring Survey, almost 56% of consumers consider a health plan’s provider network to be a very important factor when selecting a health insurance plan. 

Data accuracy is not only essential to assist consumer decision-making but it is also an important way for health plans & healthcare organizations to control costs & reduce network leakage. The cost is further compounded by fines from Centers for Medicare & Medicaid Services (CMS) and other government agency reaching as high as $25,000 per beneficiary for data errors.

So how do healthcare organizations manage the overwhelming amount of ever-changing provider information? 

Here are 5 ways to optimize your provider network data for better consumer experience & accuracy compliance.

1. ​Simplify the complexity of provider data
2. Create a single, authoritative source of provider information
3. Regularly check, score, & scrub your data
4. Enable real-time consumer support
5. Obtain consumer/member feedback