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Carla Simmons joined Certify in March 2022 and was promoted to Director of Operations in January 2024. She graduated from Tennessee State University with a BS in Cardio-Respiratory Care Science. Her previous employers include Humana and Centene Corporation. While she was born in Toronto, Carla grew up in the Bronx in New York City. Currently, she lives in Metro-Atlanta with her husband and 2 young adult children. Outside of work, Carla loves all things Arts & Crafts, as well as traveling and volunteering in her community. Carla also enjoys spending time with her family, especially with her twin sister.

Zoltan joined Certify in February 2024 as Sr. VP of Engineering. Zoltan brings a wealth of experience and passion to his role through a diverse background, including serving as a Water Polo Timing Official at Aragon High School in San Mateo, CA and coaching rowing from 2002 to 2003. Zoltan lives with his wife, 3 children, 2 cats, and dog in California. He recently participated as a panelist at HiPaaS 2024, showcasing his commitment to advancing the future of AI in healthcare.

In the complex world of healthcare, the relationships between payers and providers can often become strained. This strain, commonly referred to as "provider abrasion," signifies the friction that can arise from misunderstandings, miscommunications, and procedural inefficiencies. These challenges can impact the efficiency of care delivery and the overall satisfaction of both providers and patients. In this post, we will delve into the concept of provider abrasion and explore effective strategies to reduce it, fostering smoother and more productive collaborations in the healthcare ecosystem.

Provider credentialing is a multi-step process healthcare systems and plans use to verify healthcare providers' qualifications and competency before granting network inclusion or clinical privileges. This process ensures that clinicians are vetted and compliant with state and federal regulations. It applies to providers intending to get in-network with health plans or employed and affiliated practitioners of health systems.

Provider network adequacy is critical for compliance and patient care because it ensures that patients can access sufficient healthcare providers and services within a reasonable geographic distance and wait time. Adequate networks deliver the following:

Credentialing in healthcare is a complex, time-consuming process subject to frequent regulatory changes. Failure to keep up with the latest changes can result in significant penalties, including fines and disruptions to provider participation in health plans. Staying compliant requires continuous vigilance and efficient management practices.

Managing provider data, especially with delegated credentialing, can be a challenge. Inconsistent rosters from different entities can create data inaccuracies, incompleteness and inconsistencies which in turn, when submitted with some data cleaning and manual consolidation, pose challenges for health plans and digital health companies.

Maintaining accurate and up-to-date provider data is mission-critical; it is essential for successfully ensuring compliance and continual network quality. When provider information is current and correct, referrals are made to the right specialists, insurance claims are processed smoothly, suboptimal providers are identified, and patient care is not delayed. The urgency and significance of this issue cannot be overstated.