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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.

In 2022 Oscar Health, a national Health Plan serving 1.5M members, and Certify, the industry's premier provider data intelligence platform partnered to improve provider network operations at Oscar Health. The initial goals of the partnership were to improve the provider experience, decrease administrative costs, and improve provider data quality. These goals were going to be focused on provider monitoring, credentialing, and credentialing efforts as Oscar Health scaled their provider network nationally. Both organizations are extremely proud to say we've seen tremendous results including significant decreases in cost, more efficient operations, and improved provider satisfaction.

Vetting a medical service provider requires more than a background check. Along with exhausting administrative tasks, paperwork, and manual record keeping, a healthcare organization needs to make sure the medical personnel they approve are credible and can be trusted with their patient’s health and care.