“It is not necessary to do extraordinary things to get extraordinary results.” – Warren Buffett
This shaped our thinking around creating a Provider Ecosystem solution that can extraordinarily improve healthcare for payers and providers.
The Provider Ecosystem looks at a payer and provider’s entire spectrum of interactions. A functioning ecosystem has connected processes and secure provider data for payer integration, enabling seamless provider management.
A well-run Provider Ecosystem removes inherent manual processes and provides a better experience for payer, provider, and member while expediting transaction processing. The trick is to think of it as a whole and introduce automation to form connections in how it operates. Another aspect is to generate frictionless, usable experiences along the entire interaction chain. Who benefits? Payers, providers, and members because it introduces effectiveness in how it all works, and that affects quality of care.
When a Provider Ecosystem is connected and running smoothly, Providers and Payers can focus on what is most important—the care of people.
What is the Gold Standard for Healthcare Payers?
Healthcare payers focus on cost and quality, so the real gold standard is affordable, optimal care for people. This means reshaping their internal processes, and simplifying interactions can make everything smoother and connected. To do this, what healthcare payers need is end-to-end digital transformation. With the power of digital, healthcare payers can:
- Increase quality standards
- Meet strict compliance regulations
- Provide responsive customer service
- Decrease claims processing time
- Offer provider self-service mechanisms for 24×7 access
- Track activity with advanced reporting
This enables scalability for growth and gives health plans a solution to achieve a higher standard—the GOLD STANDARD—for provider and member experiences.
Health plans are looking to achieve:
- The ability to thrive with quality data
- Accurate claims processing
- Robust provider directory
- Expand key data fields and business rules
- Sales team enablement during open enrollment for faster and efficient processing
- Enabling members to review the rating of providers prior to enrollment
- Simplification of network-to-contracting to obtain the relevant data needed to onboard a provider without manual transactions
- Data integrity
- Self-service for provider transparency
- Online data management without manual intervention
Quality of care
- Efficiency in the system that allows providers to focus on care instead of administrative tasks – efficiency also translates to lower costs
- Optimizing the process to remove speedbumps that can delay care
Challenges Facing the Provider Ecosystem
Most providers have multiple health plans and multiple intake streams to submit required information. Removing paperwork and manual processes reduces their struggle so they can focus on creating the Gold Standard. Why should they have to live in the land of administrivia when all information is online?
The goal is to streamline operations and deliver an unparalleled member experience. Be it ensuring quick claims settlement or seamless onboarding, our Healthcare Center of Excellence at Newgen focuses on each facet of the entire ecosystem while enabling coordination between the various provider functions.
During the lifecycle of leading executive teams in healthcare, Health Plans face the same foundational challenges in building a quality network of providers responsible for the health care of members governed by Federal and State regulations. Members now look for rapid responses, increasing the need for connected micro-processes in the Provider Ecosystem.
From regulatory regulations, membership expansion to value-based contracting, health plans face multiple challenges across various departments, such as network management, open enrollment, and operations. Any delay in the process impacts the company, members, providers, and vendors in that health plan.
4 Key Problems
1. Silos in Healthcare
- Many users work on unconnected point solutions in contracting and operations departments
- Lack of an integrated system across all these departments leads to duplication of work, decreased productivity, broken processes, low transparency, and unnecessary delays
2. Fragmented Provider Data
- Health plans manage and store the provider’s data in separate systems. These systems support their own silos resulting in fragmented business processes. The outcomes are irregularities, errors, manual effort, and higher reworking cost
3. Manual and Error-prone Processes
- Most health plans are dependent on manual handoffs resulting in data entry errors
- The nature of departments requires people to manually enter or re-enter the provider’s data which translates into the loss of data and documents during hand-offs between multiple departments
- The downstream effect is manual errors in claims processing from a claim’s processor entering information incorrectly
4. Compliance Risks
- If providers’ information is parsed across multiple systems, health plans cannot manage data in a methodological way.
- The outcome leads to the inability to track the provider’s required history and difficulty in enforcing policy and procedures as well as creating compliance nightmares for health plans.
- Unresolved member complaints become CTM complaints, thereby affecting STAR’s ratings.
Furthermore, the lack of an integrated solution that includes multiple journeys of a provider with the health plan leads to data management inconsistency, operational inefficiency, and higher administrative costs.
The Solution Lies in the Connected Provider Ecosystem
The Provider Ecosystem solution is a connected approach that integrates contract management, provider/facility onboarding, data maintenance, pricing, and self-service into a connected, end-to-end system.
Adoption of the Provider Ecosystem streamlines the process, reduces administrative cost, enables adherence to compliance, and improves member experience.
By leveraging the integrated Provider Ecosystem Solution, health plans can bridge information silos to optimize the provider experience, counter the data management challenges, foster providers’ relations in the long-term, and thrive in the dynamic healthcare environment.
Think Gold Standard Provider Ecosystem Solution, Think Newgen. Here’s why
Newgen’s Provider Ecosystem solution ticks all boxes:
- A robust, frictionless provider experience
- Faster and efficient claims processing
- Automated provider management
- Responsiveness to compliance and member demands
- A stronger focus on care quality
- The ability to adapt to changing trends and needs
Newgen’s Healthcare COE is dedicated to helping payers, providers, pharma, and members. Our team has an extensive experience of working with leading payers and has the expertise to help you tackle your aspirations and problems. Think of us as your healthcare solution architects.
Will a Gold Standard work for you? Let us talk and whiteboard some ideas.
Find more about the Provider Ecosystem Accelerator here: