● Part 3


What becomes possible with integration


now face. By integrating and automating four critical func- tions — provider information management, network design, contracting, and reimbursement — plans can develop a policy-driven environment in which the complex and dynamic interactions between payments, benefit plans, and medical events are fully and efficiently synchronized. Tis helps health plans and providers work in concert to achieve a pressing goal: to better, more cost-effectively manage populations through advanced care delivery models built on some form of value- based reimbursement. We’ve looked at the reasons why the network management function is under pressure to evolve, and the pieces that need to be in place to do an overhaul and upgrade. In this last part of our discussion, I’ll describe the advantages that are gained by optimizing the network management function. I will also lay out some considerations for assessing readiness in taking this next step, and be frank about why some organizations might be hesitant to push forward, in spite of compelling reasons to do so.


A


Administrative cost efficiencies Te benefits of integrating the network management func- tion begin with administrative cost efficiencies. Improvements in the administrative domain make it easier for a health plan to enroll and manage the right providers for its programs, benefit plans, and designs. As a prerequisite for doing so, a health plan must have all the relevant data on those providers — obtained from a variety of sources (ranging from third parties to in-house analytics) and pertaining to a variety of categories (from credentials to quality measures). Te ad- ministrative efficiencies come from having a single automated system capture and manage that data, and deliver it through a solution set. Once the data is populated, the enrollment of the provider can be done very rapidly, and the management of the network is much more adroit, as we’ll see.


6


s I’ve written about in the first two parts of this series, network management must be retooled if health plans and their provider network are to meet the cost, quality, and access challenges we


Improved provider relations Another advantage to a single automated system is simplic-


ity of verification — not only for the payer but also for the provider. A portal allows providers to reach into the payer’s system and actually validate, update, and manage their own data. For instance, a provider that has changed offices, added a new team member, or updated a credential can apply that change to the system on its own and know that it will cascade automatically.


As health insurance exchanges and increased Medicaid enrollment bring an influx of high-use, high-churn members, the need for a network structure that is highly efficient in the delivery of optimal care will be essential to manage medical risk.


Te resulting administrative efficiencies are easy to imagine, and so is the improvement in relations between the payer and the provider. We have found that even providers who work with multiple payers are more satisfied with those relationships when they have access to a portal system to manage their own data. After all, time and resources are no longer wasted on administrative oversight, and reimbursements are processed correctly the first time. A robust data management system also gives payers the


ability to understand the role that providers play within a network. Tis frees the payer to think in terms of systems of providers, rather than discrete providers, and to understand the exchanges between providers along the supply chain. As a result, a payer can see the natural flow of a patient through the healthcare path and determine whether the network is adequate for a population or a particular patient. Tat kind of nuance creates more service satisfaction among every stakeholder.


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