Unveiling the Critical Role of Provider Data in Health Plan Operations

In the dynamic landscape of healthcare, the accuracy and currency of provider data have become paramount for the survival of health plans. 

My recent article in Forbes, “The Data Behind The Provider Directory: Why Provider Data Is Key,” delves into this topic and the crucial role of provider data in optimizing workflows, ensuring precise claims payments, and making strategic decisions.

Here are some of the key takeaways from the article:

  1. Comprehensive Provider Information is Essential: Provider data, covering demographics, specialties, practice locations, and more, is indispensable for compliance, precise payments, and maintaining current, member-centric provider directories. Health plans must move towards real-time updates to keep pace with a provider’s evolving profile.
  2. Transformation Imperative: The conventional practice of periodic updates is no longer sufficient. Health organizations must pivot towards embracing real-time updates as integral to a provider’s evolving profile. Technology exists to assist in this transformation, but solid leadership and change management are crucial.
  3. Informing Strategic Plan Design: Up-to-date provider data guides the development of provider networks and plan benefits, aligning them seamlessly with contractual obligations. Real-time data helps determine whether providers are accepting patients, aiding in legal compliance and member demand alignment.
  4. Streamlining Claims Processing: Accurate provider data is crucial for frictionless payment processes, reducing appeals, and minimizing rework efforts. Real-time updates to linkages between providers, facilities, and groups in a central data hub smooth claims adjudication, saving time and resources.
  5. Meeting Regulatory Compliance: Federal and state regulations mandate accurate and accessible provider directories. Non-compliance incurs heavy financial penalties and affects both provider and member satisfaction. Robust and automated data management practices ensure audit-ready accountability.
  6. Empowering Member Decision-Making: Accurate and current provider directories are essential in preventing surprise billing issues and providing a trustworthy tool for members in search of healthcare services. Robust provider data enables personalized decision-making support and enhances member satisfaction.
  7. The Foundation of Efficient Systems: Provider data, often less visible than claims, is the foundation for efficient system-wide performance. The ability to scale provider data management and implement automated processes distinguishes leading health plans in the competitive healthcare landscape.

As the healthcare industry undergoes continuous disruptions, health plans must embrace the transformation of provider data management. The technology for this shift already exists, marking a high time for organizations to automate provider data for the collective benefit of the industry.

To learn more about how Virsys12 can help your healthcare organization with enterprise provider data management efforts, view our demos and contact us today.

About the Author

About the Author

Tammy Hawes is CEO and Founder of Virsys12, a Healthcare Focused Salesforce AppExchange and Consulting Partner. Hawes launched Virsys12 in 2011, with a track record of more than 25 years of executive success.

About the Author

About the Author

Tammy Hawes is CEO and Founder of Virsys12, a Healthcare Focused Salesforce AppExchange and Consulting Partner. Hawes launched Virsys12 in 2011, with a track record of more than 25 years of executive success.