Hospital (Photo: Thinkstock) (Photo: Thinkstock)

Every patient has had the experience of looking for a new doctor online — perhaps a neuro-ophthalmologist in one’s network, or maybe it’s a genuine emergency. Instead of getting a clear-cut view, the patient is faced with several conflicting pieces of information on where these practitioner are, or their title or affiliations. Less directly, but no less typically, a patient may have had a claim or prescription rejected in error because information on the given health provider wasn’t up to date or consistent.

Enter Provider Data Management, or PDM. This is the term given to the overall system of technologies, services and procedures that helps the healthcare system to keep track of providers — where they are, what networks they belong to, what their areas of specialty are, and when they have appointments available.

(Related: Medicare Plans May Face Wave of Network Adequacy Fines)

The reality is that provider data changes quickly, frequently, and in practically innumerable ways. This means that the opportunities for mistakes are practically limitless. In fact, provider data needs to be updated regularly and consistently in order to do what it was initially put in place to do: clearly inform the correct parties of the up-to-date status of any given practitioner.

Provider data management is a critical IT need for payers and others in the healthcare space. Effective management of all this provider data is in some ways the heartbeat of a strong heath plan, since it affects the accurate and timely payment of claims and has a direct impact on the payer’s relations and interactions with both providers and members.

The more agents and brokers know about PDM, the more they can help clients unravel health coverage knots.

But what constitutes effective management of provider data? Indeed, many payers, managed care organizations, and health plans find it difficult to execute PDM effectively. Here we’d like to describe what successful PDM might look like, considering not only the fundamental complexity of the industry but the rapid changes we’re seeing as companies within it merge, grow and change. All of this points to a need for an extremely detailed, involved and thoughtful approach — and possibly a bit of technological magic — to PDM, in order to reduce the instance of confusing, costly, and trust-reducing mistakes.

Here we offer several approaches that are essential to getting the management of provider data right. First, we’ll get an understanding of its complexity and possible pitfalls. Then we’ll offer three valuable techniques to address those pitfalls.

Understanding the Complexity of PDM

These core considerations for effective PDM underscore exactly how complicated successful execution of this foundation-laying business process can be:

1. Tracking Progress

A PDM strategy that only works most of the time isn’t good enough for what is a ubiquitous, essential need for payers. Therefore, it’s imperative to have full visibility into what progress is (or isn’t) being made. If a business can’t ensure that all necessary changes are made in a timely manner, or that staff have the time and resources they need to make those changes, the door is open to claim payment inaccuracies that will only get worse with time.

A reporting and tracking method that properly orders changes that need to be made according to their stage in the cycle helps to ensure transparency, and that effort is being expended where it is most needed.

2. Making changes effectively

Hundreds or thousands of changes to existing PDM data may be needed on a weekly basis, covering everything from updating information of existing providers to adding new ones and terminating others when necessary. Unless all changes are made accurately and without delay, claims payments may be delayed or made inaccurately; teams may need to manually adjudicate claims, meaning increased costs; payers may be slapped with fines or penalties; providers may get so disgruntled that they litigate; members could hear negative feedback from providers who are not getting paid timely and/or accurately, leading to further loss of trust in the system; and worst of all, members could fail to find the right doctor in time.

Another costly error resulting from not making changes immediately might be that providers who should have been terminated may continue to get claims processed and paid erroneously. It’s so important to have the right processes in place — otherwise, requests for information or clarification that are necessary before a provider data change can be made might become stuck in a loop between two or more internal departments, further increasing the cycle time to get the job done.

3. Managing backlog

Change requests that aren’t addressed in a very short time frame lead to backlog (see above). Unless these requests can be processed immediately, they pile up and data management becomes less and less effective. Without a regular review identifying where these backlogs are, as well as daily updating of the backlog inventory via good reporting, issues with unprocessed changes can snowball.

Without Effective PDM, consequences quickly compound

Each unaddressed request for an addition, deletion or change within PDM, or one that isn’t made accurately, poses another potential problem with claims payments, provider relationships, and the all-important member experience. Unless payers recognize these issues early on and implement an effective system to address them, data snafus will only keep growing, as more inaccuracies work their way into the process.

One way this can unfold is that patients won’t see accurate information on their health plan’s website. Not being able to access accurate information on in-network providers in their area can easily lead to pressure from their doctor when they do get in, if claims aren’t paid on time. Providers can grow increasingly frustrated by delayed or inaccurate payments, to the point of refusing to work with specific payers — which of course deeply and unfairly affects the patients.

Continuing upstream with the fallout from backlogged updates to providers’ data, payers can also face fines and other penalties from failing to meet deadlines for government-backed provider programs. As mentioned earlier, terminated providers may continue to receive payments. Finances skew increasingly out of line with necessary payments. Payers’ staff are likely to face ambiguity about their responsibilities, how things get documented, and other fundamental issues, as they lack a clear work strategy and tools to engage in PDM effectively. These problems continue to grow more serious and complex over time unless they are efficiently addressed.

Three Techniques That Successfully Address Common PDM Problems

1. Assessment of New Change Requests

An effective approach to PDM requires a beginning-to-end assessment that accounts for the flow of new requests and how they are being processed. Getting this bird’s eye view helps organizations discover weak points in the system and other issues, and it allows for them to be competently addressed.

This is a great opportunity to better define processes or implement new ones, as needed. For continued, long-term success with any new system, payers must also ensure that strong, consistent and frequent reporting is in place, to keep a finger on the pulse of the process that is, in many ways, their organization’s heartbeat.

2. Executive Buy-In

Strong PDM also needs widespread organizational buy-in and cooperation. Executive and departmental leaders need to grasp that the seemingly simple concept of PDM is quite complicated in execution and prioritize it, budgeting for it accordingly.

3. Team Building

Widening the lens on the need for effective communication around PDM, there also needs to be a focus on relationship building.

While the concept of cross-functional teaming as laid out by Inc.com has probably been superseded by other management techniques, it’s a perfect fit to encompass the wide range of employees across many departments who must consistently work together to realize positive results.

They must know each other and understand individual roles, in addition to meeting regularly to discuss processes, workflow, and any emergent problems before they become more serious or escalate. Team building is perhaps the single most important consideration for effective PDM.

With a comprehensive initial assessment, consistent reporting, meaningful executive buy-in and cross-functional teams that truly understand the importance of working together, PDM doesn’t need to be a source of constant problems and worry for the plan managers, and headaches for your clients. It can be a process that helps payers, managed care organizations and health plans continue to grow and prosper — meanwhile improving member experience and, most importantly, patient outcomes.

— Connect with ThinkAdvisor Life/Health on FacebookLinkedIn and Twitter.


Julie Sampson (Image: Meir Kahtan)Julie Sampson is director of payment integrity at AArete, a management consulting firm.