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Designing a Digital Provider Network Management Platform for the Future...

As health care is gearing up for the next phase of the digital wave, the definition of the "provider" has been changing and extends beyond physicians, clinicians, and health professionals. The idea of social care network including nurse practitioners, social workers, pain /addiction counselors, and other local community organizations are getting included in the Provider networks. 


The role of non-traditional providers continues to grow within the health care system to address the patient's underlying social determinants of health such as housing, access to nutritious meals, employment and support. The provider data management has been focused on traditional episodic care, but the industry's shift towards value-based care has changed the definition and added new provider data challenges. Inaccurate data on the provider puts millions of patients at risk costing billions of dollars.

Digital Provider Experience Platform.png

Why do we need a digital provider network management Platform?


  • Accurate Provider Data for better Patient Care - Health plans and payer organizations are unable to collect and evaluate provider information across the university, local authorities and provider directories. Further, the lack of reliable sources and no standardized "standard source of truth".
  • Reduce the call volumes and administration costs - A claim processing with missing or inaccurate provider data causes payment processing failures or denials, this results in multiple calls to the provider support and health plan outreach to providers to gather and validate the information.
  • Provider a transparent and simplified process - By providing a transparent and simplified process - the response time gets shorter to whether the provider can even join the network, frustration can be reduced dramatically


What are the key challenges to address in this space?


  • Out of Date / Inaccurate Provider Info. - There is no accountability to provide clean and accurate data to the payer ecosystems. Invalid/incorrect provider contact information is detrimental to a member's access to care. 
  • Largely manual process and delayed process - Enrollment is scarcely automated, causing multiple interventions and a large amount of waiting time. There is a need for a transparent and simplified process.
  • Regulatory Risks - The regulatory and policy initiatives have increased provider data challenges causing CMS penalties and fines


How can we build a next-gen platform for Provider Network Management?


Platform design vision is to build a unified platform for provider network management which focuses on the following:


  1. Provider enrollment - Simplified personalized user experience leveraging intent-driven design for provider enrollment and personalized experience built on SF community cloud
  2. Provider Credentialing - Credentialing process should be the first line of defense to onboard a provider, but in reality, this process is cumbersome. The idea is to build a digital ledger that can onboard third parties and collates information. The digital platform will leverage SF blockchain for the credentialing process
  3. Provider Contracting - The contracting process should be streamlined leveraging Vlocity Health 
  4. Provider Onboarding and support - The onboarding is crucial and the most ignored part of the lifecycle, we would be leveraging content management for provider onboarding and self-service


Further Reading and References:

Defining the Provider Data Dilemma - CAQH

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