4 Trends for provider operations & provider network administrators in 2016

Mike Simmons, CredSimple CEO - Print  | 

This month, we're all planning for the New Year. If your health plan is like most, the last few years have been about the Affordable Care Act (ACA) and how it affects your business.

Now that we know the ACA is here to stay, it is time to optimize. In 2016, health plans will be driven by the bottom line: While the front office is striving to grow membership, engagement, and value-based contracts, the back office is focused on reducing spending and increasing quality. In the New Year, provider network administrators will embrace innovation to meet these demands.

1: Operational Efficiency
As health plans manage their workforce, two factors need to be considered to gauge efficacy. According to PwC's Strategy&, "health plans should increase the percentage of time that employees devote to value-creating work... and improve productivity during this time by getting employees to do more work at the same or better quality level within a given period."

By incorporating the lean practices and strategies used by the manufacturing sector, managers are implementing best practices across their organizations.

What this looks like: The organization must invest in solutions (not just tools) that remove busy-work and truly enable employees to devote their time to value creation. Then, divide workplace outcomes into measurable steps so managers can observe performance and determine why some perform at a higher degree of efficiency.

2: Managing Provider Data
Provider data is not a new issue for health plans, but in the last few years, new innovations in technology are changing how it is being handled. Furthermore, these developments are changing industry expectations for how provider data is handled. Accurate provider data is no longer an idea that health plans should strive for, nor is it a project that can be put off for another year. Rather, clean data is a basic need. Accurate directories are critical in providing efficient care to patients, and CMS and other regulatory bodies are including accurate provider directories in their requirements for compliance.

Managing provider data can lead to busy-work and decreased operational efficiency. The model of hiring a handful of temps to do thousands of hours of data entry, making phone calls and reviewing spreadsheets is not scalable. In 2016, more health plans will turn to best-in-class tech-based solutions that leverage provider interactions with health plans and other healthcare organizations to enhance quality and data freshness.

What this looks like: Cloud-based software continues to displace on-premises software, and best-in-class solutions for specific functions are taking market share away from the classic all-in-one suite solutions.

Nic Poulos of Bowery Capital explains: "From the enterprise perspective, the emergence of cloud software has made it exponentially cheaper, easier and faster to implement new solutions. As a result, forward-thinking CXOs are able to work with increasingly young and innovative vendors. For executives in all industries, the ability to identify and procure the portfolio of cutting-edge solutions right for their business is becoming a measure of competency in itself. Old thinking used to run that 'you can't get fired' for going with the biggest, most established software partner across the board. That's simply not the case any longer given the top-and bottom-line opportunities at stake."

3. Enrollments
With the push toward efficiency, 2016 is poised to make faster enrollment times a business objective. That means all the payer processes for activating a provider, including credentialing and transaction enrollment, must be streamlined by the payers. Driven in part by the continual pressure put on provider reimbursements, provider organizations are looking for new ways to optimize their revenue cycle and demand that payers find ways to be more responsive.

Health plans that decrease the lag time caused by enrollments, specifically credentialing, will benefit from healthier provider/payer relations and stand to see significant savings.

What this looks like: Transactional enrollment is quickly moving toward electronic funds transfers (EFT), remittance (ERA) and explanations of benefits (EOB). CAQH has opened a portal that provides "a simple, cost-effective solution to help health plans move closer to universal EFT." In addition, NCQA's credentialing guidelines are evolving to give health plans the ability to move away from paper processes in favor of automated and electronic credentialing.

4. Delegated Credentialing
For payers seeking to lower the cost of enrollment, delegated credentialing has been an option for many years, but generally, payers are able to delegate only to large provider organizations such as hospitals. In 2016, with the number of technology solutions readily available to smaller organizations, payers will drive additional cost savings. By providing their small provider groups with the technology to manage credentialing themselves or by a third-party CVO, payers can significantly reduce the cost of credentialing and re-credentialing and help providers to reduce the enrollment period dramatically.

What this looks like: With Service as a Software (SaaS) credentialing companies, both credentialing and enrollments are streamlined. With a SaaS credentialing platform, tedious paper forms become a fully integrated electronic credentialing application. Providers are guided through a streamlined electronic application and CAQH-aligned attestation questions with a release form they can sign electronically. Electronic applications simplify provide credentialing for your providers and administrators. Most providers complete electronic credentialing applications in less than 20 minutes, kicking off the Primary Source Verification process as soon as the provider presses submit. Payers instantly receive real-time analytics on the credentialing process and automatically set up ongoing monitoring and re-credential events.

The next six months will be critical for the industry and provider network administrators as more providers will make the switch to newer platforms to set themselves apart as innovators. Simply put, now is the time to critique and reevaluate current processes – it will make a major difference down the line.

Mike Simmons is the CEO of CredSimple.

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