Provider Contracting: 6 Key Business Functions To Look For In Selecting The Right Tool

Onboarding, retaining and servicing the providers within a Payer organization is becoming a core focus due to expansion into new markets and strict state and federal regulations around access to care. Providers have taken a back seat to member acquisition and retention, but as Payers move to new payment models and strategies combined with low provider satisfaction rates, there is an immediate need for a complete overhaul of the way providers are contracted. Payers are now looking at new ways to streamline the contracting process including the selection of a new robust digital platform. They will have to be careful to not fall into the same trap of selecting a system not intended for Healthcare payer contracting, systems with limited or no integration capabilities, poor reporting and not user-friendly. The business and IT teams need to work together to find solutions that will benefit the entire organization for years to come.

Below are the six core business functions critical to reducing the gap between the Payer and the Providers, while also ensuring a better user experience for all parties.

  1. Digital Contracts – The first requirement is that the solution is able to provide an Omni channel experience for Providers, so that contracts that could come in through different channels are managed within the same platform. The contract language has to be available in digital format and all accompanying supporting documents have to be stored in a central repository for all departments to access. Digital signatures are a must. Reporting on clause usage and edits within contracts will provide better insights for future contract creation and negotiation.
  2. Fee Schedules – The solution should be able to easily integrate or provide a built-in solution to manage fee schedules that are an integral part of any contract. Ignoring this core requirement will often result in a situation where claims are not paid based on contracted values or that the pricing data has to be manually keyed into the claims systems resulting in huge revenue loss to Payers and in some instance Providers.
  3. Where Am I – The business users involved with the onboarding process should have transparency into the status of the provider application from any department. This clearly reduces multiple calls to the service desk and provider anxiety during the onboarding process. This tied with robust reporting of all functions will enable a true Provider 360 view.
  4. Auto Renewals – The solution should be able to auto identify contracts that are due for renewals based on a preset threshold day (30,45 or 60 days), and the required steps for renewal should be automated. This avoids manual tracking and outreach. The system should be able to perform automated provider verifications and outreach as required for missing information or documents. Auto tracking capabilities will allow the system to track the response of the request and notify the interested parties when all required information is available.
  5. Business User Capabilities – This feature enables users to manage most of the business functions like SLA’s, required documents checklist, skills, email templates, contract templates, reports and a lot more functions with no dependence on IT teams.
  6. Unified Platform – The most important capability is the ability to manage the end-to-end business process involved in Provider onboarding. This includes contracting, credentialing, configuring and servicing. This unified platform will act as the orchestration layer for all Provider updates (Add, Update, Term) and be able to feed the data to the backend systems with minimal errors.

Selecting the right platform will enable Payer organizations to lead the marketplace and increase Provider satisfaction, but careful evaluation of the many offering is critical in the buying process and for long-term success.

 

The article was originally published on Health IT Outcomes and is reposted here by permission.

Baskar Mohan

Director - Healthcare Practice, Virtusa. Baskar has more than 18 years of professional IT experience with over 13 years of US project experience. He has worked in the Healthcare industry for the past 11 years both on the payer and the provider systems. He has extensive knowledge of the Blues and has worked with them in many corporate initiatives including the HIPAA 4010A1 conversion, SSNE and the NPI project. On the payer side, Baskar has worked on EDI and core claims systems. During his tenure at BCBSMI, Baskar has worked in EDI, Membership & Billing, Facility, Professional, Dental, FEP & NASCO to name a few. Baskar has also very good exposure to the government run Medicare & Medicaid programs and has worked for the Dept of Health Services, Sacramento, California. He also has executed a number of projects in healthcare related to BPM. Baskar is very knowledgeable of the Pega platform and in specific the Healthcare payer framework, Insurance Industry framework & CPM. More recently he has executed projects related Governance, Risk and Compliance using Pega for providers very specific to CoBIT & HIPAA. As a Chief Architect, Baskar is responsible for designing solutions for 5010 & ICD10 solutions. He has created go to market solutions to help customers transition to 5010 & ICD10. As a Program Manager, he is responsible for delivery & execution of all projects both onsite & offshore and currently manages a team of resources. As a Client Services Director, Baskar is responsible for revenues for healthcare book of business, assist the sales team with pre-sales, account radiation and client management. Baskar has experience working with global clients across, USA, UK, France & Netherlands.

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