5 great answers built on Pega

For your healthcare provider network management problems

Kuzhalan Samydurai,

Manager - Business Consulting

Published: February 26, 2018

The least prioritized (and invested) IT system, in a payer organization, is that of network management. This is, however, expected to change in the future, since payer organizations have started realizing that both provider and member service ratings, as well as Medicare payer rating, could be badly impacted by not providing the right provider data at the right time. More so, thanks to the ever floating provider population!

A recent 2017 report by CMS found that‚ 45.1% of provider directory locations listed in these online directories (MCO) were inaccurate. and also clearly points out that the discrepancies, at a minimum, will increase the member's frustration with the MAO and where inaccuracies are frequent, may significantly prevent sufficient access to care. As MAO members rely on provider directories to locate an in-network provider, the accuracy of this information is critical.

Statistics from the report

CMS issued compliance actions based on the results of our reviews. 31 notices of non-compliance, 18 warning letters, and three warning letters with a request for a business plan were issued.

Provider network management is so critical that, deficiencies in this area can increase chances of MCOs losing business, or becoming ineligible to bid for new businesses.

Further, areas that majorly impact improper provider management are those of member experience, claims payment, provider relationship and govt mandates and requirements on credentialing, network enrollment and a provider directory.

Virtusa provider lifecycle management (PLM) product with its powerful features built on top of Pega healthcare Industry framework is an answer to the industry's provider data problems.

Accelerated Onboarding

Government agencies both at the federal and state level have strict mandates on the timeline for credentialing and provider onboarding, right from the date the contract is signed.

Payers network management departments are struggling to manage this with improper workflow management systems spanning across functions such as sales, contracting, Network management, legal, credentialing, claims configuration, pricing, and provider relations.

To address this problem, Virtusa's PLM product has a ready-to-integrate, unified, single system.

Provider directory

CMS is strict on clean provider-directory, and the CMS 2017 report is a clear evidence for it. Every payer is large dollar amounts buying third-party systems for evaluating their data. But they have to realize that it is not an effective workaround and a costly one at that.

Only continual credentialing and frequent refreshing of provider directory with speedy updates will be effective for changes in provider with faster roster file processing.

Virtusa's provider lifecycle management solution has Best-In-Class capabilities built around Pega to handle the requirements, mentioned above.

Proper claims payment

Bad provider data leads to improper claims payment and this sequence results in a vicious cycle, with the progress of time. This will ruin the quality of both claims and provider data, as well result in an increase in the effort for appeals and grievance resolution.

This problem can be addressed only by validating data upfront. Virtusa's PLM solution has smartly designed and business-managed upfront validation rules for different provider types, these upfront validations makes claims payment better and reduced appeals and grievances.

Provider relationship & transparency

The maze of provider onboarding, involving at least 5 teams, and too many handoffs has led frustration among providers, keeping them in dark.

PLM's intuitive design, leveraging Pega's SLA, correspondence and reporting out-of-the-box capabilities, has enhanced provider relationship and has brought in transparency for both providers and provider relationship executives.

Liability and mandates

Robotics-automated continual credentialing, timely re-credentialing can save organizations from liabilities, as well meet the related mandates.

PLM is powered by Pega robotics and smart rules, which make Primary source verification (PSV) a part of meeting the NCQA requirements.

And this list goes on! Provider lifecycle management (PLM) tool by Virtusa is the most advanced, sophisticated tool offering a high ROI, undoubtedly!

Kuzhalan Samydurai

Manager - Business Consulting

Modernize your care, improve patient outcomes

Unlock the potential of AI/ML-powered solutions

Related content