Technology helps track healthcare providers

Comprehensive, accurate, up-to-date and accessible information on healthcare providers is a key to successful healthcare business management. Most organizations, however, have neither accurate nor up-to-date information on their providers. Moreover, information that is captured is contained in multiple silos, reduced to paper files, rarely shared and never used to control costs.

The key to tackling the provider data-management problem is through a combination of technology and outsourced services, which can pull provider data in from primary sources, and push verified provider data out to meet an organization's specific needs and requirements.

The most logical starting point for provider data management is the credentialing department. For most organizations, the credentialing department maintains the most comprehensive information related to the healthcare provider.

The process of credentialing entails the gathering of extensive background information on a provider, including basic demographics, office information, licenses and certifications, affiliations, references, education, training, and even health records. In the typical credentialing department, provider data is acquired via a paper application, which is then entered manually into a credentialing software system.

Managed-care organizations and some health systems have utilized the CAQH uniform application, which may decrease the need to directly collect information from providers. Most organizations, however, still manually enter provider information into their legacy systems. Often, there are multiple phone calls made and faxes sent to provider offices to achieve completion. The process of data acquisition on a single provider can take anywhere from several days to four months or more.

Credentialing data is generally entered into credentialing software packages commercially available for license or subscription. Often the packages do not accommodate all of the data being captured, thereby necessitating auxiliary databases. In addition, many databases do not accommodate convenient image upload, further complicating the process by requiring separate imaging databases. Uniformly, paper files are ultimately generated for review.

Process not repeated often

Healthcare organizations are required to review primary source-verified provider information. Primary source is defined as either the source of the information being verified, such as a license board, or as a secondary data repository that has been approved to act as a primary source by the relevant auditing organization. Through a combination of Web searches, faxes, letters and phone calls, the primary source verification is completed.

This process of verification occurs once every three years for most managed-care organizations and once every two years for health systems and other facility-based organizations. While various accrediting organizations have indicated the need to perform verification more often, the manual nature of the exercise deters most organizations from doing so.

Provider information is gathered by credentialing departments into verified profiles, which, along with the paper files, are reviewed by credentialing committees for the purpose of ultimately rendering a decision on affiliation. The credentialing department is also intermittently called upon by other departments for provider report information. The creation of these reports can be arduous, depending on the number of data repositories and paper files that need to be consulted.

After a decision is made on the provider's affiliation status, the process of credentialing lies dormant until the expiration of the credentialing cycle (either two or three years, in most cases). Some credentialing departments will review license sanction hot sheets periodically to see if any of their providers appear. Other than these minor review activities, provider data is rarely updated between credentialing cycles.

One final step to the provider data-management process remains. In many cases, provider data is captured separately by enrollment and contracting, claims processing, risk management and clinical systems. Often, multiple duplicate provider records are spawned, thereby leading to increased inaccuracy in credentialing records. Cleaning and updating the profiles, de-duping profiles, and maintaining current and accurate provider data is often neglected due to time and cost constraints.

The manual nature of the credentialing process produces undue direct costs in the form of labor, overhead, technology support and maintenance fees. The indirect costs, however, of a dysfunctional credentialing and provider data-management process are more profound. Inaccurate provider information infects every organization, causing increased administrative costs due to failed provider communication attempts.

Issues with patient relations and care arise from inaccurate provider directories. The lack of continuous credentials updating puts organizations at risk for patient safety issues, fraud and abuse. Perhaps even more damaging is the inability to use provider data to proactively manage the healthcare organization.

A combination approach

Both provider data acquisition and verification are processes that benefit from scale. Not taking advantage of these cost and efficiency benefits is a missed opportunity. Furthermore, removing non-core functions can promote decreased fiscal and resource stress in less-obvious areas of the organization. A solution should utilize both outsourced services in combination with a platform that can be accessed by the healthcare organization (or other parties as needed). This will produce both transparency of service along with a unified accessible provider records.

In addition, obtaining continuous verification of provider data is essential for reliability and risk management. The technology decision can be a particularly difficult task, especially where substantial investment in legacy systems has been made. Organizations need to weigh these previous expenditures against the considerable benefits of a better technology services process. General guidelines for a successful implementation include:

Commitment to change: Organization leadership should communicate to all affected personnel that the project is supported at the highest levels. The support should be shown through tangible presence at milestone meetings and swift response to resource issues.

Education: Senior management should clearly communicate the motives and benefits for making a change to the new processes and bring the vendor in to demonstrate the new capabilities that are available.

The manual nature of the credentialing process produces undue direct costs in the form of labor, overhead, technology support and maintenance fees. The indirect costs, however, are more profound.

Collaboration: The organization and vendor should engage as partners to achieve the desired improvements. Anticipate that the vendor will be a target for employees who see change as a threat. Maintain clear communication with personnel and respond quickly to dissension.

Standardization issues: Language changes for credentialing application consents and attestation forms, new types of reports, automatic notifications and changing the extent of information sharing between facilities can result in significant project delay. Changes to traditional credentialing methods and tools can spark internal strife. In multifacility organizations, personnel may feel strongly about risk-management issues associated with their preferred methodologies versus those of another organization. These issues should be identified and dealt with at the outset to save time and reduce IT charges.

Conversion: In order to achieve centralized provider data, a merger of multiple data sets into one may be necessary. The labor necessary to create a master data file should not be underestimated. There is also the issue of what personnel perform the data cleanup. Often, the existing medical staff personnel are designated to perform this process on the theory that they know the data.

The problem with this approach is that their day-to-day responsibilities will often prevent them from efficiently or adequately performing this task in a timely manner. Organizations should supplement this approach with adequate additional resources to assist in the process. By making the transition as easy on the primary users as possible, an organization will only increase internal support for the new credentialing solution and streamline the conversion process.

Published: May, 2010