Physician Network Solutions: Transforming Provider Management and Healthcare Access

Physician networks are the foundation of access, reimbursement and care coordination in healthcare. Accurate data on physicians, specialties, locations, credentials and participation is vital to health plans, healthcare organizations and provider groups to ensure networks that are responsive to member needs. As new providers come and go, as providers relocate and change practice arrangements, managing such information by hand can become difficult.

Physician network management solutions help to harmonize provider information, credentialing, contracting, and network management into a more streamlined operating model. The emphasis is shifting from keeping up with directories to creating networks that are more accurate, more accessible and meet the needs of care.

Evolving Priorities in Physician Network Management

Provider data is becoming more critical for healthcare organizations since the data impacting the provider network impacts multiple aspects of operations. A physician's specialties, practice location, and accepting status and participation arrangement can impact member access and claims processing. Providing provider records in a central location can help to increase the accuracy of the provider information and minimize the need for duplicate updating between provider systems. Data validation can also further enhance accuracy by detecting incomplete records and information that needs to be reviewed for accuracy.

Credentialing is also becoming more closely connected with network management. Before one can be a part of many healthcare networks, physicians must have the proper licenses, qualifications and professional credentials. Automated workflows can structure documentation, manage verification needs and route exceptions to members of staff. A formal credentialing program can minimize the administrative repetition and can provide better organizational oversight of provider eligibility.

Another key factor is network coverage. A network should offer reasonable access to required specialties and services throughout its population. Geographic analysis can be used to inform the identification of areas with low provider coverage, and utilization information can indicate if provider capability is in line with demand. Geographic and utilization data can be used together to provide a better foundation for network planners in recruiting physicians or changing participation agreements.

Provider contracting is also increasingly data-driven. Reimbursement terms, participation and contract requirements must be kept in sync with operational records. By using a centralized process for contract management, it is possible to monitor important provisions and find agreements that are near expiration or in need of review. Improved matching and matching of contracting records and provider records also decreases the risk of the provider's participation data being incorrect and impacting network administration.

Solving Network Management and Provider Coordination Challenges

A large number of physicians can add up to a heavy credentialing load for staff, particularly if they are required to retrieve documents and confirm information multiple times. The answer is to automate the workflow, give tasks, track outstanding documentation and make reminders for information that needs renewal. Human reviewers don't need to track most of the administrative steps, but can spend time on the exceptions and complex cases.

Physician participation is also susceptible to change: a physician may relocate their practice, switch their specialization or change network affiliations. Under these circumstances, static provider directories can easily fall out of date. Continuous data feeds and verification processes on a schedule may offer a more timely approach. Even though automated data sources can provide a lot of information, direct confirmation from providers is still important, as these data sources may not capture all operational changes.

Another challenge may be keeping specialty coverage in place, especially in places where there may be fewer physicians or services available for that specialty. By comparing provider distribution to member needs, network analytics can be used to determine geographic and specialty gaps. Specific shortages can then become the targets for recruitment, rather than general expansion. Where there is limited scope for direct recruitment, partnerships with healthcare organizations and independent practices can be an additional way of improving access.

Advancing Network Intelligence and Stakeholder Value

Advanced analytics is transforming network management from a maintenance to a strategic function. Provider data, along with utilization data and geographic distribution/specialty demand, can be analyzed to help identify areas of concern. This analysis can provide an organization with information on whether or not the network capacity is adequate for the needs of the populations being served. It also offers a more solid basis for making provider recruitment, contracting and network planning decisions.

Interoperability is another important advancement. Credentialing, contracting, claims and provider information are typically managed across multiple platforms. Standardized data exchange can minimize data duplication and enhance data flow between systems. Greater interoperability also enables updates to relevant systems to be made more regularly across operational areas.

Digital self-service can provide a benefit to provider engagement. Secure portals can provide doctors and practice administrators with demographic data, the ability to submit documents and communicate updates. These tools alleviate the double entry of manual correspondence and provide greater transparency of administrative needs to providers. The clear workflow can also help enhance cooperation, as doctors can easily see what information is still outstanding.