3 Reasons Carriers Need a Single Source of Trust for Their Provider Data

by Jake Tunney, Business Development Manager, Leap Orbit

Many carriers have legacy systems and processes that manage their provider data.  The result is a confusing array of manual and semi-automated processes to try to get accurate data to members.  When these fail, which they often do, it creates pain for all stakeholders:

• Claim denials and reprocessing costs: “We denied this claim but shouldn’t have.” 
• Confusion among members: “What is this doctor’s correct phone number/location?”
• Lack of trust among members: “Is this doctor really in my network?”
• Provider abrasion: “Why isn’t my data updated in the carrier’s directory?”

However, some carriers are taking an innovative approach to consolidate their provider data operations without upending their old processes and spurring a mutiny among staff members.  Here are three reasons why plans need a single source of trust for provider data.

1. Claims systems are not designed to manage provider data as a Single Source of Truth.  We often hear that the claims system is the source of truth for a plan’s provider data.  In an ideal plan architecture, they are downstream from the source of trust.  Updating data to a claims system is a clunky error-prone process.  And extracting data from the claims system for use in a member-facing directory gives way too much control to the claims system to define your data model and what elements you can surface to members. 

2. Credentialing Systems are not designed for contract management.  Credentialing systems are expanding to cover all aspects of “Provider Data Management.”  This includes things like Contract Lifecycle Management (“CLM”).  CLM typically requires a lot of back-and-forth communication and document management.  CRMs and products like Docusign are explicitly designed for this.  Use those instead.  We’re currently working on a lightweight CRM/Docusign Integration using Monday.com.  

3. Using a data hub gives you control.  By consolidating all provider data within a single hub, you can integrate with any downstream system.  Then, each system is using the same data.  A good data hub can: 

• Create different “views” for each system of the same data.  For example, a directory might need things like accessibility and languages while a claims system needs TIN and NPI.  
• Use a “Source of Trust” methodology.  That way you know the source and update date of the data element you’re using.
• Enrich data with primary sources (i.e. state boards, CMS, NPPES, DEA, OIG, etc.)
• Clean up and standardize your data.    

Below is an example of a health plan’s system architecture that leverages this type of architecture.  If you’re considering moving to this type of modern infrastructure, contact us here.