Before founding Virsys12, I started my career as a software developer in healthcare and ultimately held rolls as a CTO and CIO. It was evident to me that there was room for improvement in the automation of business processes in healthcare to eliminate waste and improve efficiencies. We believe there is no better place to start than the process of provider network management (PNM).
The process of onboarding, credentialing and contracting providers to serve a member population is a critical aspect of healthcare delivery and involves managing the relationships between healthcare providers and payers. In 2023, the importance of effectively managing the provider network for health plans cannot be overstated, as it can help health plans build strong provider relationships. This can allow health plans to collaborate with providers and help them ensure that their members receive high-quality, cost-effective care while also managing costs and improving health outcomes.
We’ve worked with many accountable care organizations (ACOs), health plans and specialty provider network organizations as they navigate the regulatory and business changes in healthcare. Over the years, we’ve seen how difficult, tedious and labor-intensive it is for these organizations to offer reliable and effective products or health plans to members and to develop new markets for primary care and specialty networks.
The shift from fee-for-service to value-based care in order to pay providers based on the value they provide to patients rather than the number of services they provide is increasing the payment calculation complexities. However, we’re seeing that many providers continue to be paid fee-for-service. All information about the providers is necessary for the production of a comprehensive and up-to-date provider directory that members can use to find physicians, hospitals or other healthcare services that their health plan covers.
Health plans need to be able to adapt quickly to these changes to remain competitive and provide high-quality, cost-effective care. Effective PNM can help payers identify new providers and services that can enhance their networks and meet the evolving needs of their members.
Credentialing ensures that providers meet certain quality standards as well as have the appropriate training and certifications to deliver high-quality care. Enrollment is the process of adding providers to a payer’s network. Effective credentialing and enrollment processes can help payers meet the contractual requirements they have with states, employers and the federal government in having adequate coverage for the members they serve. Many states require this process to be completed within weeks, and technology can help accomplish all of the steps necessary to perform these tasks.
The centers for Medicare & Medicaid Services noted that most provider directory data is estimated to be roughly 50% inaccurate. Regulatory requirements and timelines for payers to complete the PNM lifecycle are likely to become even more complex and demanding. Effectively managing these processes can help health plans meet these requirements and avoid costly fines and penalties.
Health plans can begin the journey toward a solid PNM strategy by making it easier for providers to collaborate and apply for the network. A simple step forward could be the automation of the provider application when building new or existing markets. Additionally, look for technology that takes an enterprise approach to the process. Many technologies solve one piece of the provider network journey but do not have the ability to deliver the automation of processes from provider application through credentialing and, ultimately, to contracting and the production of an accurate provider directory. Many organizations underestimate the internal change management required to implement a complete solution. Develop internal champions that can drive change within your organization to ensure success with an enterprise provider network solution.
PNM can provide the basic building blocks for health plans to build strong relationships with their network providers, adapt to the evolving healthcare landscape, manage costs, meet regulatory requirements and ensure adequate provider coverage for their members, and maintain accurate and up-to-date provider directories. By prioritizing PNM, health plans can provide quality, cost-effective care while also improving health outcomes and reducing unnecessary spending in the healthcare system.