The Perfect Prescription for Provider & Practitioner Contracts

Harry Angel
Harry Angel | Sales Director North Amercia, East

If you are a Health Insurance Payor or Plan Organization, the following may sound familiar:

  • Your IT systems have grown more complex over time from acquiring businesses, geographies and technologies
  • Some of your systems are new, others were developed decades ago by people who are long retired
  • The number and complexity of interfaces between Provider, Plan and Claims systems is difficult to manage and requires a significant amount of expensive manual effort to keep running
  • The number of disparate systems and databases have grown
  • You have many Silos of redundant data that have evolved over time because of technology limitations or reporting demands
  • Different databases, different technologies, different business units, different plans, different administrators
  • You have multiple systems and market channels for publishing practitioners, credentials, sites and office hours, all while regulatory requirements demand access to accurate data quickly by plan members

From a Payor’s or Plan’s perspective the challenges of keeping all the information in sync are magnified when additions, changes and deletions of providers come at you from emails, faxes, snail mail and online portals. Information can be handwritten, typed, submitted in letters or provided in standard forms.

In order to migrate from current state to an efficient and effective future state you need to first establish a strategy for a single, unified repository of Provider and Practitioner data and contracts. This requires a platform that allows you to add data and functionality as you gradually start to eliminate those legacy, siloed systems. At a high level, your ultimate system needs to support the following data relationships.

Practitioner Data relationships

 

Since all data is driven from the Legal Entity or Provider, this is Phase 1 of functionality that needs to be replaced.  All contracts and related data should be supported in this first phase, with interfaces to related site and Practitioner information. Intake requests for adds, changes and deletions can be managed based on the departments, activities and workflows of your organization.  New Artificial Intelligence engines can also now expedite the extraction of data to start the intake process.

Phase 2 would entail adding data and functionality to maintain the related Site and Practitioner data driven from the Provider data. All remaining upstream legacy systems can then be retired, and all downstream systems would then be interfaced accordingly and driven from a single, unified repository.

You cannot “boil the ocean” by replacing everything at once, due to complexity of data, systems and processes. A gradual migration path to continually sunset legacy systems for a unified repository is the logical and risk averse approach.