Payer innovation council weighs improvements to provider data management experience

An innovation council brought together some of the nation’s largest health plans to raise issues and look for ways to improve complex processes, including credentialing and provider data management.

It’s one of the first times payers have sat down together to solve these pain points, CAQH CEO Sarah Ahmad told Fierce Healthcare in an interview. The health plan representatives met in-person just one day before AHIP 2024 kicked off in Las Vegas last week.

“You don’t see that in healthcare these days,” said Ahmad, whose company assembled the leaders.

CAQH is a provider data management company that works on the provider side to credential and handle directory management, and on the member side to handle coordination of benefits.

“One of the biggest issues that payers, as well as providers and members, [have] is the data quality they’re seeing in a directory,” she explained. “If you don’t have that information correct … a lot of things can break down.”

Directory information includes provider addresses, tax ID numbers, office hours, specialties, if they’re accepting new patients and more. Should that information be outdated or incorrect, patients will struggle to attend appointments and access providers.

In credentialing, Ahmad says many of the same problems that existed 20 years ago are still issues today. The credentialing process, required of providers looking to obtain verification and be part of a payer’s network, can be long and arduous.

To simplify the process, CAQH raised the idea of creating a universal roster, where a provider would fill out necessary paperwork once, instead of duplicating efforts with every payer a provider contracts with just to be part of an individual network. That universal roster would be shared among payers and drastically reduce administrative burden.

“I think the biggest problem has been getting all the payers aligned,” she said. “I think when it comes to provider data we still have some ground to take because the complexity of getting everyone to agree.”

She also said that she knows the federal government is looking into improving directory management frustrations, and urged officials to listen to health plans in order to come up with the best solutions.

Tech vendors flock to payers' annual gathering

Plenty of businesses offering technical products and services had a presence at this year's AHIP.

symplr, a provider of healthcare operations software solutions, released a new suite of services at the show that is designed to help payers credential more efficiently through automation.

The company says its products, on average, help payers handle 60% more members and at a 30% faster clip, allowing payers to grapple with larger networks.

“Data management has been an issue since the beginning of time,” said symplr Chief Marketing Officer Kristin Russel, adding that inaccuracy and noncompliance with federal legislation results in penalties and internal organizational stress. Additionally, provider directories are notoriously complex and often contain inaccurate information.

Its offerings are three-pronged: A data management and security tool that is HITRUST certified, provider search to improve member satisfaction and a credentials verification organization that is accredited by the National Committee for Quality Assurance. While symplr offered these products individually, the collection of solutions are now fully integrated, allowing payers to break down silos through end-to-end provider data management.

Russel told Fierce Healthcare that few other credentialing companies help payers as comprehensively as symplr. The company helps manage nine of the top 10 major national payers’ credentialing provider systems and more than 400 payers across the country, allowing insurers to contract with fewer vendors.

PointClickCare also co-presented a session with Humana at AHIP. As a result of a recent partnership, more than 1,700 inpatient admission notifications and discharge summaries were sent to providers in Humana’s pilot region network per month. This is especially useful as patients move from acute to outpatient care when continuity of care is often an issue.

Nicole Sunder, senior director of solution design at PointClickCare, said payers are able to aggregate, summarize and make visible contact information to a health plan by using the company’s tools. Health plans have said they see a significant reduction in ED visits among people that were able to see a primary care physician for their condition, ultimately helping payers improve quality scores.