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Provider Information Management

Getting ahead of the reform storm

Three steps to supercharging provider information management. By Sam Muppalla


he universe of provider information is rapidly expanding and changing across the healthcare ecosystem. Whether you are a payer introduc- ing innovative benefi t designs, or a hospital

implementing a pay-for-performance (P4P) program, you are counting on reliable provider information. Provider information is the undervalued currency fueling your successful response to reform. Payers are responding to the Patient Protection and Af- fordable Care Act (PPACA) and other market pressures through innovation and by revamping cost structures on multiple fronts. Their products are being redesigned to incorporate value-based benefi ts and are being tailored to meet the specifi c demands of their customers. Payers are preparing to differentiate their products and services in the homogenizing world of health insurance exchanges. New provider networks are being designed to deliver the promise of these new products while new reimbursement models are being introduced to align the performance of providers with the value expected by employers and customers. Additionally, experimentation with collabora- tive care models, such as the patient-centered medical home, is in full swing. Provider information that spans access, quality and cost dimensions is critical to each of these initiatives. Reliable provider information is a cornerstone of the payer focus on administrative simplifi cation and accuracy. For example, an accurate electronic claims payment process requires identifi cation of the service provider, attribution of the appropriate contract governing the services delivered, as well as the corresponding payment methodology. This, in turn, requires accurate provider demographic information and codifi ed information on the payer’s multiple relationships with the provider. Streamlining other core processes, such as marketing, medical management, provider relations and customer service, is also contingent on reliable provider informa- tion.

The capability to manage accurate provider informa- tion is increasingly becoming a key differentiator and an

24 November 2010

asset for provider organizations, as well. Hospitals, along with other provider organizations (such as accountable care organizations, or ACOs), are under growing pressure to show evidence of the consistent application of medi- cal best practices and guidelines as their reimbursement rates may soon be predicated on such evidence. In addi- tion, patients and employers are demanding greater trans- parency about provider credentials, experience, quality, costs, convenience factors, language skills and site details. All of this is in an effort to help members/patients make more informed health and wellness decisions.

Hospitals are under growing pressure to show evidence of the consistent application of medical best practices and guidelines as their reimbursement rates may soon be predicated on such evidence.

While provider information is becoming increasingly critical to both payers and provider organizations, ensur- ing its accuracy and integrity can be very challenging. Provider information is typically distributed amongst disparate systems with varying levels of data quality and duplication. Furthermore, provider information is usually accessed, utilized and modifi ed within multiple process silos leading to fractured and partial data sets. The man- ual handoffs between these process silos contribute not only to ineffi ciencies but also to data errors and latency. Data integrity rules are either manually or inconsistently enforced. The expansion of the information set to accom- modate growing business needs represents another key challenge. Meeting this challenge demands high levels of fl exibility in the systems storing provider information. By its nature, provider information is highly dynamic, both inside and outside the walls of the organization. For example, in any given year, approximately 15 percent of


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