How Provider Data Affects Payers and Why You Should Care

Data management has been a huge topic of conversation lately, especially Provider data. To many, Provider data feels like it should stay a provider problem, the truth is that it affects healthcare payers in a significant way. Inaccurate or disorganized data can result in negative outcomes for patients and severe financial challenges for health plans.

Data and risk management is everyone’s concern, especially as we ride the pandemic rollercoaster. Both payers and providers want to give their patients the best health outcomes, but without interoperability, this becomes impossible.

With such a massive amount of fragmented and unorganized data coming from health systems all over the United States, how can Payers keep up and avoid missing crucial information?

We’re going to dive into the ins and outs of provider data, care coordination challenges, and how health plans can streamline their own processes and optimize the data that they receive.

Provider Data Challenges

Data challenges boil down to one big issue: the lack of an industry-wide solution for provider data. Payers are sitting in the middle of a debris storm, trying to catch and organize data as it is flung at them. Rather than the funnel that it should be, health insurance companies are constantly attempting to consolidate millions of data points.

This results in administrative burdens for payers and delays in care for patients. According to CAQH’s recent white paper, Defining the Provider Data Dilemma, “One analysis estimated that commercial health plans and providers alone spend at least $2.1 billion annually to maintain their provider databases. It was estimated that 75% of those costs could be offset by integrating with an external source of truth, if such a source existed.”

Care organizations need a real-time universal data solution, that is the undeniable truth. Otherwise, high quality care in the midst of a pandemic becomes increasingly difficult. Especially when it comes to claims management.

How Provider Data Affects Payers

The main arena where the burden of organizing data is felt is in claims management. When a claim is missing provider data, or there are inaccuracies in that data, this causes payment delays,increases the processing time and inaccurate payments.

Particularly when it comes to value-based care models, this is even more important as providers will not be paid until specific outcomes are met. If payers aren’t getting the right information on time, this results in even more delays in payment for providers and overburdens payers.

In addition to payment delays, the burden that inaccurate or incomplete data places on the administrative claims processing staff may lead to high turnover rates and difficulty filling open claims processing positions due to lack of experienced potential candidates.

Healthcare government agencies are working to provide a solution to the data interoperability issues currently plaguing health and care organizations, but until a universal data solution is found and universally implemented, payers have to cushion the provider data blow.

The right solutions improve outcomes

While there isn’t a one size fits all solution to the provider data dilemma, there is one thing that health plans can do to weather the storm. 

SymKey® is a intelligent robotic process automation solution to help health plans process healthcare claims more efficiently.

HCIM has been a trusted partner in the industry for over two decades, applying innovative technology to help automate business processes. Our team of industry experts help organizations reduce operational costs, allowing staff to focus on more complex tasks. 

For more information on how we can help you turn complexity into simplicity, contact us to speak with one of our experts today.