Data Challenges that Health Plans and Providers Must Navigate

Nov 30, 2021 | Blog

By: Scott Alsup, Senior Vice President of Operations at Verisys

How to Maintain Compliance and Data Integrity Despite Disruptions in the Healthcare Environment

Care coordination systems revolve around the processes and people that affect a patient’s quality of care. Well-designed care coordination can increase patient retention anywhere from 25 to 95 percent. However, the challenge of getting response rates, information completed, and getting providers into a network in an unprecedented amount of time (10 days or less) can be a daunting task. In order to successfully respond at an accelerated rate, solid processes, coordination, and agile technology are required. At Verisys, this is how we get results in compressed time requirements.

Compliance Challenges Facing Healthcare Providers

The bottom line is, it’s our job to get healthcare providers in network to see patients as fast as possible.  But there are some significant roadblocks that can be detrimental and expensive for health plans.

Getting provider responses and helping them understand health plan requirements is the fundamental challenge. For example, if I want to see my favorite doctor but that doctor is out-of-network, that’s a higher cost to the health plan and me to see that out-of-network doctor. Neither health plan nor patient wins in this scenario.

Compliance Challenges of Telemedicine Providers

COVID has introduced another level of complexity as it has driven telemedicine to rapidly expand. Before, a provider could only deliver care in one or two states, maximum, due to geographic barriers. Now, one provider can see patients in all 50 states.

One big challenge with this is making sure that the provider is in compliance with all the varying requirements within those multiple states. Another challenge is getting providers contracted with the health plan so that they can start to see patients rather than spending valuable time learning about the requirements of each state.

With each state requiring its own set of rules, regulations, and processes, it can be very difficult for health plans and providers to navigate. Let me give you an example- New Mexico requires that you send a letter to the provider via certified mail. You must log and document that the mail has been received. If overlooked, the results can create compliance risks for both providers and patients.

Researching each state’s specific requirements can be a minefield for the providers to straddle. In addition to that, state requirements may not line up with what health plans want. That leaves gaps of missing information.

Health plans need their own internal compliance monitoring system for each provider. This is especially critical when staying in compliance with Medicaid and Medicare, which carry significant fines for noncompliance. Industry best practice would have health plans credential their providers at a Medicaid level of scrutiny. In doing so, if a provider wants to participate in a Medicaid plan down the road, they won’t have to go through credentialing all over again.

Building Solutions for the Challenges Health Plans and Payers Face

I spent 25 years in the steel industry where I dealt with just-in-time deliveries. I’ve brought some of those principles to the healthcare space. There are two common challenges that I’ve seen in manufacturing and healthcare: forecasting is tough, and timelines are tight. The following solutions to these two challenges are required to meet healthcare’s changing needs.

  1. Forecasting is tough. In manufacturing, forecasting is difficult. You compensate by creating finished goods, or you build materials ahead of time because eventually, a particular part is going to be needed. This way, when the part is needed, you can deliver it very quickly.

In credentialing, forecasting is equally or more difficult. Unlike manufacturing, we can’t build any finished goods and we can’t predetermine what provider is going to be ordered from which health plan. We must react quickly to changing environments and handle a lot of fluctuation in order patterns. To do this, we’ve built tools internally to be able to quickly assess our ability to absorb additional work. By doing so, we can shift and shuffle if we need to do overtime or we can push work to another team.

Every morning we review our new orders, look at our current orders, look at due dates, and review staff capacity. We can assess and shift any assignments immediately because we’re big. With an operations team of over 200 people, we have the capacity to pivot and make it happen. This is significantly different from what you may find in an internal shop of 10 to 15 people.

  1. Timelines are tight. The second thing that typically happens in manufacturing is if the plant is running at maximum capacity and new orders come in, the lead times move out – meaning it takes longer to get that product. That’s not the case in the healthcare world, because we have regulatory and contractual obligations for turnaround times, regardless of what our workload is. We must balance our capacity and be able to adjust to those fluctuations on demand.

The fast response times and our ability to handle volume fluctuations are where we add significant value to our providers, facilities, and payers. Most of our clients can do what we do in-house, however, it’s not necessarily a core competency. Many clients don’t have a huge amount of investment in that area, so they don’t have efficient tools, automation, or staffing. Most organizations are trying to keep staffing at a minimum which unfortunately puts them in the position of not being able to absorb fluctuations well. Limited staff and capacity can create issues for them as they’re trying to start up new networks and clean up or maintain provider files.

Because Verisys thinks about credentialing all day, we have more flexibility, tools, and capacity. Credentialing is what we’re focused on, and it shows. Our expertise and experience really help make the solution better for our clients and that’s why our Net Promoter Scores (NPS) have continued to climb. We set another record this year which is indicative of how our clients feel about us.

When clients come to us with special projects, compliance projects, or new network builds that need to happen urgently, we work with them to build up their network and keep them compliant. One client came to us with a large group of providers that somehow got missed in their system. They asked us to expedite their credentialing. Within about three weeks, we were able to process the orders, get results back to them, and help them resume their compliance.

How to Structure Your Team for the Changing Needs in Healthcare

During COVID the healthcare field witnessed a huge staffing shortage. Recovery from this shortage may take a decade. Staffing shortages included both medical and administrative teams, specifically in dental, healthcare facilities, and service locations such as x-ray, physical therapy, labs, and more where COVID hit particularly hard. In many areas, demand for elective procedures dropped significantly, resulting in reduced revenue and staff. As a consequence, many offices have further slimmed down staff which means lower response rates and higher dropout rates.

In the meantime, many providers kept themselves busy working in more offices or became part of a larger network. These factors, combined with changing telemedicine regulations, could result in providers becoming transient, working in multiple offices, and servicing patients in multiple states. This is especially impactful for recredentialing which is on a three-year cycle.

The bottom line is that there is more movement and less dedicated administrative and support staff (in fact, there may not be any at all in some cases).

The staffing loss is taking a huge toll on compliance and credentialing. After the last two years, the data that health plans have on transient providers is often not current, making it a challenge to track down those providers. But it’s not limited to transient providers alone, facilities are running shorter hours with less staff and less revenue. This means less time and resources dedicated to credentialing and the processes that follow.

The situation may seem daunting for practices and facilities that have been hit hard, but it isn’t impossible. You need a flexible, dedicated team to fill the gap. If our team gets an order from a client and they’re not in good status or we don’t have the application, we start doing outreach, Google searches, and phone calls. Because of our incredible dedication, capacity, and flexibility our conversion rates from not having an application to getting one is about 80%.

While high conversion rates take dedication, they must be accompanied by a commitment to precision. This requires a team you trust. The wrong information could be detrimental to not only the provider but also to the health plan. You must combine a dedicated team that is committed to quality data with high conversion rates. It’s a lot of manual labor to acquire missing information necessary for full compliance. Additionally, turnaround time requirements are becoming shorter; they have decreased from 30-45 days to 10 days or less. Getting quality information at high conversion rates within this time frame requires solid processes and coordination.

To stay in compliance with changing requirements and challenges in care coordination and credentialing, you need a team that sees your compliance and processes as a personal commitment. Verisys combines the best technology and credentialing software with a dedicated, experienced team committed to quality data. If you’re concerned about changing regulations, shorter turnaround times, and the shifting healthcare culture, reach out to our dedicated specialists to augment your team.


Verisys Written by Verisys
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