Provider Lifecycle Evolution, Part 1: How to Begin

The Provider Lifecycle

In our January blogs, we shared how a provider lifecycle strategy can unify approaches to directories, enrollment, credentialing and more to restore provider trust, bolster engagement, and ultimately convert your provider network into a growth lever.

While regulatory pressure and compliance matters, health plans are increasingly adopting a lifecycle approach to solve business problems:

• High operational cost of acquiring and managing the data behind the provider lifecycle.
• Duplicative costs from a fragmented approach across credentialing, enrollment, and data management.
• Poor business outcomes from fragmented data – high inappropriate denial rates, high costs to work appeals and sub-satisfactory network strategies.
• Provider abrasion and dissatisfaction – molasses-like credentialing timelines and numerous, redundant information requests.

Everyone wants a future where this just works – but getting started is intimidating. Let me share with you my insights from partnering with numerous health plans around the country to build something better.

Prioritize for Smooth Execution

“Where do we start?”

There is no right answer for everyone. Your approach should be right for your organization and usually weighs factors like signals from your providers, most painful area, highest costs, or plain old readiness from those teams. If we’re starting from scratch, here’s how we’ve seen it work best:

• Critical First. Credentialing is the strongest entry point. The nature of credentialing makes it the most critical step, as it sets the foundation for the payer-provider relationship. Errors and discoveries at this stage can derail everything that comes after it. 
• Provider Importance. Credentialing is also the area providers tell us is the most painful for them. Quickly signaling to your network that you intend to design for ease and agility is a strong way to get providers to pay attention and engage.
• Data Foundation. Credentialing’s information request is usually the widest and deepest. This gives us the strongest foundation when building a unified data model that next steps can run with.
• Keep the Flow. Make sure the data you capture at credentialing doesn’t get stuck there. Flow that into the attestation refresh and the rest of the lifecycle stages.

A provider lifecycle approach treats the recruitment and upkeep of provider status as a continuous lifecycle, not a set of disconnected steps.

Stay on a Single Page

We see the wheels come off provider lifecycle changes when internal teams are not focused on the same priorities and philosophies about trade-offs. Unclear ownership and siloed decision making are the most common ways we see this manifest. The most successful teams make top-down and horizontal alignment a priority:

• Executive-level sponsorship across silos – Bring in your leadership to align the functional areas of credentialing, provider data, directory, claims, and anywhere else provider data is used.
• Clear business-IT partnerships and translation from technical requirements to use – how does the data structure support each use case?

Misalignment and communication failures are the Achilles’ heel of any change program, and provider lifecycle evolutions are no exception.

Foundational Readiness

“How do we prepare?”

I can’t tell you how many times we’ve been in review of a health plan’s roster and no one in the room is sure why they’re collecting “address line 3” or “alternative after hours correspondence phone number.” It might feel like a small thing when you look at a question on a form in isolation, but for providers nothing is isolated. We must keep a laser focus on the reason behind our requests. 

When we first set out on this journey, we find that many health plans can’t explain their own data model. Outsourced vendors, temporary contractors, and years of technical debt have compounded until it’s hardly recognizable. Invest the time to align the business use case and the facilitating technology:

• Understand provider hierarchies and relationships.
• Map out how data needs to land within the operational systems across your ecosystem.
• Place value on all downstream use cases, not just directories – faster credentialing, right decisions on claims and auths, and more.

Health plans that isolate provider data for directories see lower returns on their investments, under-utilization from providers, and perpetuation of all the same problems.

Conclusion and Part 2

Health plans setting out on this journey are saying to their providers and members that they intend to provide better experiences for care provision. These first steps are the foundation that will determine if you’re set up for success, or it crumbles out from under you. Take the time to prepare to succeed and you will.

Interested in how to stay on track, measure improvement, and the one key secret to success? Later this month, we’ll release Part 2 in this series where I’ll dive into how to sustain improvement and deliver a system that’s built for better. Keep an eye on our LinkedIn and Blog sections of our website!