The Need for Provider Network Management in Healthcare

When someone is ill, all they really need is a fast diagnosis, the right prescription or treatment, and a speedy recovery. Time is of the essence, and dealing with an illness is stressful enough without added complications.

But the reality is far from ideal. Patients often find themselves navigating a complicated maze of different doctors, hospitals, and clinics, each with its own rules and procedures.

Plus, many healthcare facilities waste a gigantic amount of money on nonclinical administrative tasks—around $950 billion in the US alone in 2019. 

That’s where provider network management (PNM) comes in, playing a crucial role in ensuring access to high quality care within an insurance network.

Moreover, it helps healthcare facilities save time, money, and resources on nonadministrative endeavors.

In this article, we’ll explore what provider network management is, what core tasks and processes it takes care of, and why there is an urgent need to have healthcare provider network management systems in place.

What is Provider Network Management?

Simply defined, provider network management is an internal system used by health plans to efficiently manage the network of healthcare providers they contract with. This management ensures timely onboarding, consistent quality assurance, and commitment to regulatory compliance.

Moreover, it verifies the qualifications and experience of providers, guaranteeing they deliver increased access to high-quality care.

Here’s what a PNM function does behind the scenes:

• Visibility and Accuracy: PNM enhances the member base’s visibility into accurate provider information.
• Data Management: PNM reduces provider administrative burden through efficient management of credentials.
• Tracking: Provider network management helps plans track the entire provider lifecycle—ensuring that providers adhere to quality standards throughout the tenure of their inclusion in the network.

Typical Management Tasks and Processes in Healthcare Provider Networks

Managing documents, files, and logistics for a team of specialists is no easy feat. Efficient provider network management makes it easier for healthcare networks to manage these tasks.

Here are some examples of the manual effort and pitfalls that PNM helps with:

• Onboarding Providers. Adding new providers involves a lot of verification and scrutiny. Healthcare facilities need to collect documentation and onboard professionals that meet quality standards. PNM speeds up this very slow and error-prone process so that patients can access the needed care without any delays. 
• Credentialing. To ensure that your patients are safe and do not suffer malpractice, PNM automates credentialing—confirming a provider’s qualifications, experiences, and licenses. With automation, there’s a significant reduction in the risk of human errors. Manually verifying everything can be very time-consuming and full of inconsistencies—with the added risk of violating compliance protocols.
• Contracting. Contracts come in complex legal language with very difficult financial terminology and jargon confusing even the most well-informed readers. Provider network management streamlines this process by tracking the products and contracts in which providers are enrolled, which reduces the risk of claims denials, leading to poor provider experiences.
• Maintaining Records. When it comes to healthcare, it’s imperative that data is safe, accurate, and up-to-date. Any inconsistencies could lead to unimaginable consequences. Thus, provider network management ensures that all the data is accurate and secure through a centralized system—preventing confusion and potential privacy breaches. 

Needless to say, manually doing all of that can lead to errors and delays.

Benefits of a Well-Managed Provider Network

A well-managed provider network is beneficial for both the providers and the patients.

• Benefits of Healthcare Provider Network Management Systems to Patients. A well-managed provider network can reap the following benefits for patients:
  • Improved Patient Experience. Provider network management ensures accurate provider directories and simplifies communication. This reduces the overall fatigue and frustration on the patient’s end, who is already going through a messy health situation. Also, it saves time and facilitates smooth care transitions between doctors. This helps with medical continuity in procedures—benefiting the patients in the long run. 
  • Reduction In Waiting Times. With efficient network management and smooth communication, there is a significant reduction in wait times. Finding appointments becomes easier—granting quick and convenient access to quality care.
  • Health Equity. Healthcare provider network management drastically removes bias from the system, promoting diverse and accessible networks. This allows everyone to find qualified professionals within their cultural background and needs. An increase in culturally competent provider matching has been shown to improve clinical care outcomes. It also cuts down stereotyping, bias, or racial stigma within the credentialing system. 
    
• Benefits of Healthcare Provider Network Management Systems to Providers. A well-managed provider network can benefit providers in many ways, such as:
  • Collaboration. Provider network management fosters clear communication and cultivates relationships based on transparency and fairness between patients and providers. This promotes better-coordinated care, enhances patient experiences, and ultimately leads to improved patient outcomes. Plus, providers have all the support and resources to deliver quality care. 
  • Automation. Healthcare provider network management helps you automate credentialing and data management tasks—utilizing provider intelligence. This saves providers valuable time to focus on patients and attend to their needs with more focus and detail. 
  • Cost Saving. Around 30% of healthcare expenditure in the USA is connected with administrative costs. By streamlining processes and cutting down on errors, PNM can help save healthcare costs for everyone involved, including patients, providers, and insurance companies.
  • Proactiveness. A well-managed provider network helps you monitor the performance in real-time, identifying and addressing issues quickly. This ensures that the patients get high quality care timely, boosting the provider’s credibility by a mile. 
  • Compliance. Provider network management allows efficient data management and reporting, helping healthcare facilities stay aligned with complex regulations and protected from penalties and malpractice lawsuits. 

How PNM Helps Healthcare Organizations Comply

The Affordable Care Act (ACA) has been revolutionary in bringing some very necessary changes in the healthcare system—legally enforcing compliance on all parties involved for the betterment and benefit of patients. 

It places a strong emphasis on network adequacy and quality—which means that insurance plans must offer patients access to a sufficient number and variety of qualified providers within their network.

It increases the cognitive effort for healthcare organizations, and they now have to ensure their provider networks meet these stricter standards and avoid potential legal punishment.

But don’t worry. Provider network management can help you stay in line with ACA policies and comply with the following:

• Network Adequacy. PNM can help healthcare organizations build and maintain a strong network that includes a versatile range of qualified providers. There’s an emphasis on how a team of providers should bring multiple specialties to the table from varied geographical locations. That way, patients within the network have access to the care they need.
• Monitoring. PNM systems track, monitor, analyze, and interpret provider performance data. This can include patient outcomes, satisfaction ratings, and compliance with care quality standards. With consistent monitoring, healthcare organizations stay on top of potential setbacks, by identifying and addressing any bottlenecks or issues that arise proactively. 
• Data Management & Reporting. Provider network management ensures that data is managed seamlessly and efficiently throughout the systems—which is something very crucial in complying with ACA regulations. This data management includes maintaining accurate provider information, documenting quality metrics, and submitting required reports to regulatory bodies.

What’s the Best Platform for Provider Network Management?

Certify can help you juggle licensing, credentialing, enrollment, and continuous monitoring without any hassle.

Here’s how:

• Automated Provider Credentialing. Certify offers API-first credentialing, licensing, and enrollment to payers, health systems, and rapidly scaling digital health companies. It provides real-time, automated NCQA-compliant credentialing to scale provider networks.
• Automated Ongoing Monitoring. The platform ensures your provider networks remain compliant through automated ongoing monitoring.
• Streamlined Licensing Process. Certify takes the guesswork (and paperwork) out of licensing, allowing you to scale to new markets seamlessly. It offers streamlined processes for cross-state licensure across all 50 states for any license category.
• Streamlined Payer Enrollment Process. The platform makes it easier for providers to join insurance plans in new markets so they can start seeing patients sooner. It also allows you to track enrollment progress with individualized dashboards.
• Provider Data Intelligence. Certify utilizes a best-in-class methodology to clean, normalize, and enhance your provider data. It can plug directly into your workflows to backfill, update, and monitor key provider information.

So What Are You Waiting For?

Save time, reduce costs, and demonstrate compliance. Reach out to sales@certifyos.com to chat with a member of our team—or request a demo to see our platform in action.

Frequently Asked Questions

Why is provider network management important?

Provider network management is an absolute necessity in healthcare because it ensures that patients have access to high-quality care at the right time.

What challenges are associated with provider network management?

Some of the challenges include keeping up with varying requirements by jurisdictions maintaining updated provider directories, managing data updates, and compliance with regulations.

How can technology help with provider network management?

Technology can help automate several processes, saving time and legwork. This automation streamlines provider onboarding, contracting, credentialing, and claims payment setup.