Monday, September 26, 2016

Optimizing Payer and Provider Communications: A Necessary Burden or Strategic Advantage?



Exchanging data between healthcare providers and health plans/payers has been a contentious subject throughout the 23 years I’ve been working in healthcare IT. Physicians have long expressed dissatisfaction with the time they and their staffs spend interacting with health plans. And all the federal and state mandates laid on providers and health plans over the past decade have not improved matters.

This Friday, September 30th, a tweetchat will be held at 10:00am PT/1:00pm ET to discuss “Optimizing Payer and Provider Communications.” The chat is being sponsored by Availity and will be co-hosted by Mark Martin, Director of Product Management for Availity, and me, Steve Sisko.

The chat will explore the communication challenges between providers and payers and the ways in which communications and data sharing between healthcare providers and health plan payers can be improved and optimized.

What are the Topics?

For the list of topics that will be discussed, see this page at Availity’s web site.

What is Provider Data?


Provider data, simply put, is information about individual providers, groups of providers and institutions—who or what they are, how to access them, the services they provide, the health plan networks or products they participate in and other important attributes. These data facilitate everyday business and regulatory transactions, or “use cases,” such as claims processing, credentialing, contracting and licensing, and allow patients to find and access care. While provider data is conceptually straightforward, it is incredibly complex to standardize, manage and maintain.

Which Providers & Health Plans Exchange Data?

The short answer? ALL OF THEM! But several factors do influence the types, volumes and frequencies of data exchanged between health plans and physician practices. These include:

1. Type of Health Plan: Medicare, Medicaid, Commercial, ASO, etc.

2. Product Type: PPO, HMO, POS, HDHP, FFS, etc.

3. Provider Type: Primary Care, Specialist, Imaging Provider, Pharmacy, Lab, etc.

What Type of Data Do Providers & Health Plan Payers Exchange?

The following types of business transactions demand the exchange of data between healthcare providers and health plan payers:

1. Eligibility & Benefit Inquiry
2. Prior Authorizations
3. Contracting including Practice and Provider Directory
4. Pharmaceutical Formularies
5. Billing/Claims
6. Credentialing
7. Treatment Plan Compliance Monitoring
8. Quality Measures

These data may be exchanged at different times – at time of contracting with the provider, pre-patient visit, upon patient check-in, during the encounter, upon checkout, or retrospectively, irrespective of the patient. In addition, certain transactions may not even apply based on the health plan type, product type and provider type.

As Mark Martin notes in Leveraging Technology to Enhance Payer-Provider Relationships, "the key is to forge pathways where these two spheres of data (provider and payer) can overlap and be leveraged to benefit both stakeholders."

Critical Provider Data Use Cases and Common Data Needs
source: www.caqh.org
Some Background Materials

The following studies, blog posts, articles and white papers provide additional information about data exchanges between medical practices, providers and health plan payers.












"Provider Data Management"


But Wait! There's More!


For more information on healthcare data, technology and services, consider following me and Mark Martin on Twitter.

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