Provider Data Management: The Business Case for Collaboration

It has become increasingly clear that the entire provider data system is at a breaking point.

Every stakeholder is struggling:

• Payers are scrambling to ensure that their data is accurate to stay in regulatory compliance, as well as to prevent a mounting administrative burden and minimize member and provider abrasion.
• Providers are struggling to keep up with the massive amount of administrative work required to maintain accurate data, ensure patients can locate them, and ensure that their claims are paid.
• Healthcare administration teams are buried beneath manual provider data management (PDM) workflows that waste hours of unnecessary time and cost millions of dollars.
• Regulators struggle to maintain compliance in a system riddled with misaligned incentives.
• And all the while, patients simply want what we all want: to access accurate information for healthcare providers so that they can receive the care they need, when they need it.

With every player in the PDM system struggling, the question arises: What is the solution? Is there a way to address the distinct needs of all parties to resolve the PDM issue? How can we support the millions of businesses, providers, and patients who are currently affected by this issue? And most of all, how can we do so without spending a fortune or adding more work to an already inundated workforce?

In the following article, we aim to explore these questions and present a case for a collaborative solution that addresses the pain points of each group, while laying the groundwork for the future healthcare system.

PDM for Payers

Insurance companies and employers are facing the most considerable burden when it comes to PDM. The truth is that payers want their provider data to be accurate—patient care and, ultimately, member satisfaction are directly attributed to offering care from credentialed providers who are in-network through their plan. Still, keeping up with constantly changing information by using legacy technology with misaligned incentives costs payers millions of dollars every year.

The Impact:

Payers are responsible for keeping accurate provider data, but the systems they have in place to manage this data are outdated and cumbersome.

• $75 million could be saved each year by streamlining PDM.
• 20% of administrative hours are spent on PDM.
• 35% increase in administrative efficiency reported with a modern tech stack.

What Collaboration Looks Like:

Every payer has a different method for collecting, updating, and storing data, resulting in piles of unnecessary work, ever-increasing inaccuracies, and a constant struggle with degrading data. By collaborating to utilize a single source of truth supported by innovative technology, payers can save millions of dollars and ensure data accuracy and integrity.

PDM for Providers

While payers are responsible for maintaining provider data, providers are responsible for ensuring that their data is up-to-date and accurate. This results in an unwieldy, manual process that involves an estimated 30 hours of administrative work annually per provider. The volume of this administrative workload leads to rising costs and burnout, and the manual processes introduce errors.

The Impact:

Much of the burden to maintain accurate provider data falls on providers, costing them valuable time away from patients and adding to a staggering administrative burden.

• 54% of providers report a recent increase in credentialing-related denials.
• 18 or more network systems to update when a provider changes their address or credentialing information.
• $738 estimated spend per provider each cycle spent on updating PDM forms.

What Collaboration Looks Like:

In the past, providers were stuck with a heavy administrative burden without much incentive to prioritize this work. If payers were to collaborate on a single source of truth and introduce tech-enabled methods to ensure data accuracy, the workload for providers would be decreased, and accuracy would lead to fewer denied claims.

PDM for Healthcare Administration Teams

Healthcare providers are responsible for sending accurate data; the hospital and clinic administrative teams are often the ones responsible for this task. Manual processes, such as typing out faxes, lead to hours of wasted time and increased burnout. Hundreds of hours (and billions of dollars) could be saved if these administrative teams had access to modern, tech-forward solutions that streamline tasks and ensure accuracy.

The Impact:

Daunting workloads and archaic processes lead to escalating levels of burnout. Millions of dollars could be saved by introducing tech-forward infrastructure designed for efficiency and accuracy.

• $25 billion could be saved by automating manual processes, such as PDM and credentialing.
• 38% lower administrative costs when manual workflows are automated.
• 30% of IT costs could be saved by adopting modern technology.

What Collaboration Looks Like:

By updating the tech stack to include a high-tech, modern infrastructure, healthcare administrative teams will be freed up to focus on tasks that directly impact the patient experience. Moreover, with AI-powered technology running behind the scenes, provider data would remain accurate even as provider information changes, resulting in lower administrative costs and improved regulatory compliance.

PDM for Regulators

The 2022 No Surprises Act mandated that all payers maintain accurate provider data to ensure that members could find in-network providers as needed, and avoid unpaid claims or excessive out-of-network charges. As a result, regulators were given the nearly impossible task of ensuring that all payer-provider data was accurate, while simultaneously managing the increasing administrative burden required to update data systems.

The Impact:

Recent legislation requires data compliance for all payers, leaving regulators to oversee adjustments to a system that is riddled with inaccuracies and fundamentally flawed.

• 1 to 5% error rate on data entered from manual workflows.
• Up to a $25,000 fine for a single error in provider data.
• 600,000 hours of regulatory burden on Medicaid compliance alone.

What Collaboration Looks Like:

Collaboration to ensure that all payers have a single source of accurate data accessible to all would ensure that payers are in compliance with the law and that all patients have access to the provider information they need.

PDM for Patients

Ultimately, what matters most in the entire healthcare system is the patient, and good provider data management is one way to ensure that every patient receives the care they need, when they need it. Patients aren’t worried about the systems in place to maintain provider data or the work it takes to get there—they just want to find a doctor who can treat them and know that their claims will be paid.

The Impact:

When a patient needs care, they rely on provider directories to quickly find an in-network provider in their area. When this doesn’t happen, patients miss out on care, and claims are delayed or unpaid.

• 53% of patients found inaccurate information when searching for a healthcare provider.
• $400 million in claims were denied in 2020 due to provider eligibility issues.
• 6 in 10 patients reported a problem using their health insurance to get care in the last year.

What Collaboration Looks Like:

Collaboration on PDM isn’t about competing for patients, but about ensuring access to healthcare for all. This means that all payers and systems work together to build a single source of truth, providing accurate information so that every patient can find the right provider and have their claim paid.

The ROI of Collaboration

Every player in the healthcare system is impacted by clunky provider data management, and every party will see direct benefits from change. It starts with collaboration—payers, providers, healthcare systems, regulators, and patients need to get on the same page.

CertifyOS is Building This Foundation

Our architecture is a collaborative, modern provider data infrastructure designed to revolutionize the entire PDM system and provide much-needed support for the whole industry.

We aren’t looking to digitize broken workflows or offer narrow point solutions that address part of the problem, but instead, to reimagine the entire foundation. Thousands of primary sources power our single, continuously updated AI-verified source of truth, which is available through a single API.

We aim to be the ties that bind all players together and bring much-needed collaboration and support to everyone involved. This collaboration will pay off with millions of dollars in savings, thousands of hours of time, and a system that works for everyone involved.