Custom Provider Data Solution Improves Quality, Compliance, and Cost-containment
In order to be an effective and reliable data steward, it’s crucial to have high-quality data and optimized provider data management (PDM). Sagility was able to provide this, along with optimized credentialing and re-credentialing of a growing but struggling health plan.
About the Client
The regional health plan in question provides coverage to more than 400,000 lives in the United States. Because they were growing so quickly, the health plan was struggling with limited in-house PDM capacity, audit compliance, and data quality and accuracy.
Provider Data Management Operations
The key to having solid provider network operations is to have reliable data and data management. Upon investigation, Sagility learned that the client didn’t have enough quality control, workflows, and project tracking in place. This led to an influx of incorrect and imprecise data, as well as a network that was 3x overinflated due to all the disparate data. The result was fragmented information and an inability to view a comprehensive provider profile.
In addition to their data issues, the client also had a very slow turnaround time in regard to transaction processing. As a result, they were often in violation of the No Surprises Act, which led to unsustainable penalties and fines. Poor turnaround time also led to a significant increase in provider abrasion and CSAT of the plan’s provider network.
Finally, because the health plan was growing so fast, it was unable to keep up with PDM capacity. Not having enough in-house PDM capacity contributed to inaccuracies, rushed entries, and slow turnaround time, all of which damaged the client’s reputation.
Creating a Blueprint for PDM
Phase one of Sagility’s restructuring program was to get an in-depth analysis of the client’s process of credentialing and provider data management (PDM). Upon inspection, we quickly realized that the client had inadequate tracking, workflows, and quality reporting in place, which led to inaccurate and incomplete data. Additionally, because of all of the disparate data being input by humans, the network was inflated three times what it should have been.
To remedy these issues, Sagility built a comprehensive blueprint to optimize PDM, credentialing, ongoing data validation, and re-credentialing. We did this by leveraging our deep domain of network operations experience that’s derived from a combination of people, processes, and technology.
Launching the Program
With the blueprint and automated solution in place, we launched the Provider Directory Validation process. We did this using a 10-person team stationed in Manila, Philippines, and they were able to ensure that all existing and incoming data was validated within 90 days of the launch.
Implementing Provider Forward
With the Provider Directory Validation process in place, we were able to address the client’s key objective – ensuring quality PDM, having quality, unfragmented data, and reducing costs.
Sagility addressed these objectives by leveraging our purpose-built network operations tool, the Provider Forward platform. Provider Forward is a single-sign-on platform with built-in CRM. It also features multiple third-party databases and interfaces. This allows for enhanced workflow management and the management and stewardship of quality, up-to-date data.
The improvements that the client saw were remarkable and nearly instantaneous. Every aspect of their operation was suddenly streamlined, automated, and optimized, which eliminated numerous issues. From intake and assignments to tracking and monitoring, the PDM, credentialing, and re-credentialing have seen stark improvements.
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In Re-Credentialing Turnaround Time
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