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BUILDING TO VALUE-BASED CARE WITH PROVIDER NETWORK OPERATIONS

By Simanta Paul, Assistant General Manager, Practice

Preparing for tomorrow’s challenges is a tall order for health plans. The
provider network operation front line, in particular, is at the center of a
perfect storm of pressing market conditions—from escalating, costly labor
challenges to damaging provider abrasion that can easily build to member
abrasion. The inherent network database inaccuracies shouldn’t be underestimated
as just operational and physician satisfaction bottlenecks. These discrepancies
can prevent patients from accessing the care they need, leading to poor health
outcomes and satisfaction levels. Additionally, the spotlight is now even
brighter with recent No Surprises regulations requiring providers and payers to
keep patients informed about the costs of care and their personal financial
responsibility throughout the care journey. 

The race to respond is on—and health plans are now completely rethinking the
fulcrum point of provider network operations—so they are both strategic and
sustainable. Enter the end-to-end provider network management solution, which
provides a future-ready platform that facilitates end-to-end provider data
operations. The results include improved accuracy for enhanced provider and
member experience, as well as significant cost savings.

Your Provider Network Team needs a better way. Unlocking value with provider
network operations means a forward-looking, fresh approach and a solution with 4
essentials:

1. Resolve breakdowns and bridge gaps with one platform. Provider network
operations is no stranger to today’s labor challenges. This area is rife with
employee burnout resulting in repetitive and unrequired administrative
processes.  Many provider data inaccuracies stem from inefficient, error-prone
back-office operations supported by disparate and disorganized systems. A
seamless, end-to-end system transforms provider data management for: enhanced
provider experience, accuracy, compliance, and plan performance. The right
platform will be scalable and flexible—consolidating various network management
features into one platform. As a single source of truth, built-in analytics can
access the vast universe of provider network data. And an optimized system will
go one step further—to proactively provide suggestions to amend or modify a
health plan’s network. This tool can bridge that sometimes steep payer-provider
gap, with omni-channel communication features that sit on top of this platform
for seamless and frictionless dialogue. 

 

2. Deliver better journey navigation and experience with digital. Simple fact:
there is no way to provide an optimized customer journey without digital.
Today’s healthcare customer expects cost-effective, quality healthcare. Members
searching for providers will most likely encounter frustrations and stress.
After all, this is probably one of the most important buying decisions they will
make. But this search is made easier and less confusing with an Amazon-level
concierge experience, bolstered by a straight and fast path to provider
selection.  Provider data is best supported with digital solutions that can work
together in a unified and real-time way to address interconnected pain
points—ultimately aiming to:

Improve member experiences and address the entire journey. Enhance flow of
information and visibility through better data access. Introduce self-service
portals that assist with information gathering. Simplify the overall healthcare
experience journey, with more effective and efficient automation.
From the digital front door to back-office efficiencies—provider network tools
can’t be underestimated for addressing many touchpoints, to satisfy two of
health plans’ key stakeholder groups: both members and providers.

3. Ensure interoperability in your chosen model. Don’t make the mistake of
investing in technology without built-in integrations and APIs to the data
sources used for provider data validation. Without seamless integration, data is
siloed and lacking optimized verification to complete the providers’ onboarding,
credentialing and contracting experience. With interoperable technology, payer
directories are updated seamlessly, with data available in a format to ease
health data exchange between providers and improve public health reporting, a
need highlighted by the COVID-19 pandemic.

4. Improve your provider relationship management and reduce abrasion. The adage
of “you can’t manage what you can’t measure” is taken one step further here—for
“measure and share.” Poor provider data management is a key cause of abrasion.
Frustration can even extend to members/patients, resulting in lower quality
ratings and even disenrollment. Enter data sharing as one key component of
payer-provider collaboration. To create a value-based care model, detailed data
sharing decrease administrative costs such as unnecessary correspondences
requesting missing information or supporting documents that lead to provider
fatigue. With the right platform, providers can submit applications
electronically to streamline communications and reduce administrative burden.
Additionally, providers can keep directories updated with a portal feature to
help health plans avoid penalties. With the right provider network tool, plans
and providers can work together and coordinate a win-win-win, for payer,
provider, and member-patient.

The future is here

In all of these areas, outside consultants have the solutions, designed with the
optimal mix of digital experience tools and experience acumen, to open up
avenues of more innovative provider data management. These partners can provide
end-to-end impact with high-value solutions that can impact downstream processes
such as claims adjudication and member calls. With a coordinated approach to
provider data, ROI can be significant. Case in point: Sagility’s Provider
Forward provider network management solution has achieved for one top five payer
client $3 million in annual savings. Value-based care tools like this bridge key
payer-provider gaps, seizing opportunity to resolve lack of data standards and
fragmentation—for collaborative focus on member/patient, and improved outcomes
for all.



Related content: Healthcare

BY SIMANTA PAUL,
ASSISTANT GENERAL MANAGER, PRACTICE

Simanta leads the Global Practice for Provider Network Operations. Simanta is
responsible for building strategies and solutions that help payers address
industry related challenges with a focus on reducing cost and streamline
operations.

Recent blog posts:


SAGILITY FUTURE-CLASS DIGITAL SERIES: HOW BACK-OFFICE ACCELERATORS ARE STEERING
OPTIMIZED EXPERIENCE


SAGILITY FUTURE-CLASS DIGITAL SERIES: FRONT-OFFICE ACCELERATORS


3 FRESH IDEAS FOR WINNING THE COMPETITION FOR HEALTHCARE TALENT


3 PAYMENT INTEGRITY IMPERATIVES IN POST-PANDEMIC HEALTHCARE


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