With a range of new challenges on the way, it is more important than ever for the healthcare industry to deliver effective Provider Data Management.
Provider Data Management (PDM), the ability to keep track of providers’ data, is one of the long-standing challenges of the healthcare industry, costing over USD 2 Billion per annum according to CAQH, a non-profit alliance that creates shared initiatives to streamline the healthcare business.
CAQH estimates that each physician practice further spends USD 998 per month and one full staff day per week only on directory maintenance. This excludes several indirect medical and administrative costs that are hard to quantify owing to differences between processes and systems across health plans and practices.
Adding to the existing challenges, there is now a raft of new regulations and requirements – such as CMS’ interoperability and burden reduction rules, new member-experience measures and the No Surprises Act. In the absence of timely and efficient PDM, providers are beset by perpetual data update requests. Furthermore, consumers may receive surprise bills and payers face the risk of non compliance and fines.
It is, therefore, more important than ever that healthcare providers’ data and network status can be accurately held, updated and monitored within the cyclical period of operations or within two days of receiving a notice of change in regulations. Managing this system effectivey, reduces the chance of compliance-related penalties as well as member dissatisfaction.
Mobilizing Big Data to Support Healthcare Providers
Even at the best of times, managing provider data can be a complicated business. Say that each provider has around 140 data points. A practice with 10 providers and 20 health plan contracts might have to manage around 28,000 data points each quarter. Across the US, such information is gathered from over a million providers and from more than 6,000 hospitals and clinics. Health plans further transfer provider claims data to multiple downstream applications and provider systems.
As the formats and frequency of data gathering vary greatly, maintaining updated, accurate and accessible information is a mammoth task. Recent industry consolidations have made the situation more complex. In the past, health plans have addressed this issue using ad-hoc data clean-up campaigns and a directory to update requests.
The ideal way to do this would be to create a Single Source of Truth (SSOT) around the health plan. An SSOT architecture is increasingly needed, given the extra requirements being placed on players in the healthcare industry.
Establishing an SSOT framework would remove the problems caused by data fragmentation as it would centralize data from practices in a single, easily updated master database. From here, it would flow to applications downstream. With all relevant parties accessing this single base, all transactions across plans and providers could be handled in a consistent manner. Such streamlined operations would use blockchain, Master Data Management (MDM) and automation solutions, and improve provider experience while making internal health-plan processes more accurate and efficient.
Upgrading PDM: Practical and Cost-Effective Solutions
Given the sensitive nature and scale of healthcare data, as well as the complex systems and regulations surrounding it, SSOT is a challenging goal to achieve. To start with, health plans must invest in robust provider analytics solutions to review their existing provider database. They can then understand the patterns in provider data and drive actionable insights for their teams. This will empower data operations and campaign management teams to collate data through the providers’ preferred channel while driving provider engagement.
There are a number of strategies that health plans can adopt to improve their PDM operations while developing an SSOT model. These include bolt-on platform-agnostic and technology solutions.
For instance, incentivizing accuracy is important. While providers are not required to share data at particular intervals or in a set format, health plans are penalized by regulators for errors. This is prompting a growing number of health plans to implement automation solutions to manage provider data. A number of companies are investing in robotics process automation as well as intelligent automation solutions to ensure accurate and error-free data management.
Updating data from multiple external data sources (CAQH, NBD, etc.) is also a challenge for providers. Around 2 percent of provider demographics change each month and 20-30 percent of physicians update their employments each year. Even minor incentives for providers to carry out updates can bring benefits in this situation.
Other initiatives can include a uniform approach to sharing data, such as a single, simplified pre-populated intake channel. The use of data templates within and across plans can also help. As can the scheduling of updates at set periodic intervals, such as the last week of every month.
In addition, there are now multiple digital solutions that can drive efficiency in data management. Self-service provider apps or portal integrations can, for instance, send update reminders. Artificial Intelligence and Machine Learning can scan a multitude of data sources to gather the most recent provider information from claims data, customer service connections, and social media profiles and communities.
Data Management Solutions, where integrated with all provider data input sources, can be used to constantly monitor provider data sets and hierarchies. This ensures that the data collected is clean and up-to-date. Cognitive solutions within provider data operations can interact with a variety of intake channels to ensure that updates from providers are accurate and timely.
Finally, blockchain technology has the potential to manage provider data not just at a health plan and practice level but across multiple plans and practices making it much easier to gather and maintain updated provider data.
Data complexity impacts many processes in the industry, including claims payments, payment integrity, credentialling and directory maintenance. As health plans and healthcare providers aim to meet the new challenges, their immediate strategies must focus on cleaning and maintaining existing provider databases. But ultimately, the transition to an SSOT provider database is necessary as it offers the ideal solution to the problem of fragmented provider data.
Mark Halford is Corporate VP of Client Services for Life Sciences and Healthcare, WNS.
