Why It’s So Hard to Get Provider Data Management Right

Provider data management is a common struggle for healthcare organizations, but most organizations don’t fully comprehend why provider data is so difficult. Like many core healthcare data elements, provider data participates in multiple processes, involving numerous internal and external stakeholders. However, provider data has a uniquely complex data structure with data elements maintained by multiple parties.

This means the business processes dependent upon provider data are impacted by data management gaps across all parties involved in the data maintenance process.

To shed more light on this topic, let’s review some of the key types of data of ownership for provider data.

Fundamental Data Ownership – The fundamental ownership of core provider data is relatively straightforward. Individual providers (i.e., practitioners) are employed by provider organizations that are businesses with non ambiguous identities. Both practitioners and provider organizations must register with regulatory agencies that assign unique identifiers to comply with regulatory registration procedures.

• Provider Organizations – Each provider organization is a distinct legal entity; however, these entities may choose to operate under multiple trade names, which is one of the first areas where we start seeing variability in provider data.
• Practitioners – Practitioners are distinct people, but also utilize alternative names for convenience and they may change names due to marriage or other life situations.
• Regulatory Agencies – These agencies include the Internal Revenue Service (IRS), Centers for Medicare & Medicaid Services (NPPES), Drug Enforcement Agency, Licensing Boards, etc. They offer some insulation from the name variability by requiring Providers to register using their legal names, but there is still some possibility of timing gaps for updates. Additionally, establishing effective integrations to maintain updated regulatory data requires significant effort due to a lack standards across regulatory agencies.

Contractual Data Ownership – Practitioners contract with health plans through provider organizations. These contractual relationships introduce the next level of complexity in provider data management because a single practitioner may contract with a health plan through multiple provider organizations. Contracting through multiple entities gives practitioners flexibility to take advantage of the benefits available from each contracting vehicle.

• Direct Contracts – Contracting directly with a health plan can lead to reduced costs and increased ability to negotiate specific terms, however, it introduces significant complexity and administrative effort for independent physicians who have to manage direct contracts.
• Managed Service Organizations (MSO) – MSOs offer services that can offload much of the administrative effort related to interacting with health plans in exchange for a fee to provide these services.
• Independent Physician Associations (IPA) – IPAs offer an expanded range of services that include contracting on behalf of smaller provider organizations to increase negotiating power. IPAs also offer services that reduce administrative effort.
• Accountable Care Organizations (ACO) – ACOs offer provider organizations another option for increasing negotiating power while also reducing the administrative effort required to participate in value-based care arrangements.

Credentialing Process Ownership – Maintaining accurate credentialing records is a critical compliance process, however this mission critical process also has divided ownership with direct contract providers going through an internally managed credentialing process and other providers going through a delegated credentialing process.

Network Participation Ownership – Similarly, the party who is responsible for credentialing also has responsibility for making timely updates to provider demographics and network participation data.

Putting it All Together

This is only a high-level of summary of the ways provider data ownership is fragmented, and the reality is that this fragmentation is not likely to go away soon, if ever. This ownership fragmentation introduces a lot of parties into the provider data maintenance process and creates inherent process variability. Unfortunately, typical healthcare applications and processes are not up to the challenge of providing effective solutions that deal with the reality of provider data challenges. As a result, the industry struggles with provider data maintenance. These data maintenance issues have significant impacts across the processes that depend on quality provider data.

• Provider Data Maintenance – Provider data maintenance teams are overwhelmed by the number of requests they receive, and without adequate IT support many of these teams have adopted a strategy of making updates by exception. Between internal and externally managed provider networks many organizations have tens of thousands of provider records, but they must limit their focus to processing updates for providers who are going through a credentialing update or who are experiencing an exception with Claims payment.
• Credentialing – As a regulatory process, health plans have no choice when it comes to staying on top of credentialing and recredentialing core processes. However, this still ends up being a highly manual effort and ensuring timely and accurate consumption of updates is an ongoing challenge.
• Contracting & Network Management – Healthcare is a complex business and keeping contract and network participation accurate across tens of thousands of providers is a challenge due to the sophisticated nature of provider affiliations. This adds yet another source of updates that must be effectively propagated through the system to ensure that providers are not over/under compensated.
• Claims Payment – Claims payment is the point where all the upstream challenges of provider data accumulate and begin having visible critical impacts. Missing updates to critical provider demographic data results in poor auto-adjudication rates, which puts a strain on administrative staff who are already overburdened. Missing updates to contract and network data results in denied or improperly paid claims, increased financial risk and Provider abrasion.
• Provider Directory Management – Provider data issues also create challenges in the member experience. Modern digital experiences demand the ability to deliver accurate provider and network data to the fingertips of Members within seconds, 24 hours a day, 7 days per week. The inability to provide an accurate view of who is available within your provider network is not only a reputation issue, it also puts more administrative burden on your staff to fill the gaps in the form of customer service calls.
  
  

What does it Take to Get Provider Data Right?

Getting provider data right takes a holistic approach. There is no way to avoid dealing with multiple data owners and multiple data sources, but you can unify all your provider data and apply a consistent set of rules to create a reliable view of provider data for the enterprise.

The real challenge doesn’t come from having multiple credentialing processes nor does it come from having a separate team managing contracts, credentialing, networks and claims. The problem is that companies are ultimately lacking the sophistication to coordinate the decisions and data managed by separate processes into a common representation of provider data.

Before you say aha, that’s what we’re going to achieve with our data warehouse let me share a few more key requirements. Your common view of provider data has to go beyond reporting and analysis. Data warehouses are essentially read-only target systems that provide increased visibility but do not provide any assistance with keeping your core operational systems aligned. It’s unavoidable to have some overlapping data elements across contracting, credentialing, network management and claims systems due to the nature of the processes managed by these systems. However, it is completely avoidable to have misaligned data across these systems. The right solution for provider data management must support reporting and analytics but also must keep shared data synchronized across your core operational business processes.

Requirements of a Modern Health Data Management Platform?

Modern healthcare businesses require the ability to engage an extended ecosystem of participants that span multiple organizations. Partnering effectively requires the ability to support multiple integration approaches. Additionally, you need tools that can be accessed by data owners outside your corporate boundaries to help close gaps for ecosystem participants who lack the sophistication to establish effective system-to-system integrations.

Integration is necessary, but not sufficient, you also need to the ability to capture a full representation of provider data that spans all process contexts, and you need the ability to manage business rules that bridge gaps in core systems to ensure provider data remains aligned across those systems.

With the right platform you will not only be able to eliminate gaps in provider data quality, but you will also eliminate delays and manual efforts that increase costs and stakeholder abrasion.

Conclusion

If you’re ready to take control of your provider data management processes and reap the benefits of reduced administrative overhead, elimination of process delays, and increased member and provider satisfaction then it’s time to move to a health data management platform that provides robust provider data management capabilities.

Gaine Coperor™ Health Data Management Platform (HDMP) can meet you where you are. Giving you the ability to unify your provider data across multiple data owners and disparate systems and simultaneously integrate your core provider data systems in a manner that keeps data aligned across your core operational processes. The right platform will also provide out of the box capabilities to incorporate data validation with regulatory agencies, further reducing both administrative burden and also reducing your technology integration burden.

Click here to contact us about having a Gaine health data management expert discuss your specific needs and how we can help address them.