Case Study: Healthcare

From-scratch provider data stewardship earns wins in quality, compliance, and cost-containment

Health plan experiences immediate improvements in PDM and credentialing/recredentialing with Sagility

Overview

High-quality data is at the heart of optimized provider data management (PDM) and credentialing/recredentialing.

One growing health plan struggled with limited capacity for in-house PDM, data quality and accuracy issues, and audit compliance.

100%Accuracy to re-credential

60%Turnaround time improvement in credentialing

30%Cost reduction through labor arbitrage and process reengineering

Client background

The client is a regional health plan in the U.S. with more than 400,000 covered lives.

Business challenge

With an ongoing challenge of provider data management, fragmented information, and lack of ability to view a comprehensive provide profile, the client struggled with provider network management operations.

Additionally, turnaround time of transaction processing contributed to potential provider abrasion and diminished CSAT of the plan’s provider network. With the No Surprises Act coming into play, penalties became costly and operating margins suffered. That’s when the client decided to transition to a fully digitalized and automated platform.

Sagility delivered a solution that combined credentialing, provider data management/validation, and recredentialing and Re-credentialing into one landscape, minimizing human effort, and providing provider data accuracy through analytics and an end-to-end view of provider profile.

The solution

A blueprint for PDM

Sagility began with an in-depth analysis of the client’s credentialing and provider data management processes. The client had limited quality reporting, tracking, and workflows in place. Due to lack technology, the network was inflated 3x with disparate data.

Leveraging deep-domain network operations experience—across people, process, and technology—Sagility built a blueprint for PDM, credentialing, ongoing data validation and re-credentialing success. The plan started with workflows and reporting—then automation, with an eye toward automating credentialing, recredentialing, and provider verification. This end-to-end process rebuild was essential to fully optimize the client’s
network operations management.

Nearshore Support

A 10-member team launched the Provider Directory Validation process from Manila, Philippines and ensured that data is validated within 90 days.

Purpose-Built Network Operations Tool: Provider Forward

To address the client’s key objective, Sagility leveraged our Provider Forward platform.

Provider Forward is a single-sign-on (SSO) platform which has a built in CRM for workflow management and is interfaced with third-party databases for quality and updated data.

Provider Forward helped in streamlining fragmented processes, inventory, and compliance tracking with visibility at the provider level from a contact center perspective. Today, the client has better control over data and through our analytics model, making process improvement decisions much easier.

Results

From intake and assignments to tracking and monitoring, the client has experienced immediate improvements across PDM and credentialing/recredentialing. Automated workflows, outreaches and follow-ups are supported by standardized templates for auto email acknowledgements to providers. Additionally, Sagility manages audit samples (sampling method and size), audit templates and overall audit process along with quality score reporting along with trending, along with effective monitoring of aging and TAT of inventory. The client agreed to augment this services with provider data validation.

62%TAT improvement for Recred and 54% TAT improvement for Cred

99%Quality improvement for Recred and Cred

90%TAT improvement for PDM

99%Quality improvement for PDM

30% Credentialing and PDM, control over inventory and interactive dashboards

25%Increase in team size and future account growth

Global locations

USA • India • Philippines • Jamaica • Colombia

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