Provider Database Management

Delivering Quality and Cost-Containment with Provider-Forward Innovation

Today’s payers are increasingly looking for a cure for the critical and costly issue of inaccurate provider data. A recent HHS survey uncovered data errors in half of the doctor listings for Medicare plans.

Inaccurate or poorly managed provider directories present significant challenges for payers, including:

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Dissatisfied members

Poor directories are more than just a hassle. They are critical barriers to care and the cause of unexpected medical costs.

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Provider abrasion
Multiple departments of the typical health plan are already in frequent contact with providers’ offices for myriad data requests. Add provider directory requests to those, and you’ve got an acute case of abrasion.

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Fines and penalties
The consequences for poor provider data management fall entirely on health plans in the form of stiff federal and state penalties and member lawsuits.

HGS PDM Solution

Internal solutions to this problem, including marshaling additional resources and greenlighting net-new technology investments, are often cost-prohibitive for most organizations. HGS’s Provider Database Management (PDM) solution integrates cost-effective people, process, and technology, including a proprietary analytics /AI led platform integrated with a CRM to manage end-to-end provider data. This platform features include a robust inventory management solution, a wellintegrated CRM that uses machine learning to improve the connect ratio based on historical successes, and a predictive model algorithm that prioritizes the queue to increase successful data collection.

We deliver provider data updates and maintenance from three unique geographies to ensure real-time updates. Our proprietary “Data Remediation” tool, Provider Forward, enables us to conduct planned outreach campaigns to collect provider data. Data collection and verification activity is performed outside of our clients’ core systems. The tool can provide cleaned output files in most industrystandard formats.

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HGS Provider Forward, Value Delivered

Client Challenge:
HGS was tasked with automation enablement to accelerate PDM ROI for one payer client.

We created a detailed Re-engineering and Transformation Project Plan to radically change the operations delivery while optimizing the customer experience. One of the chief objectives for the client was a solution that addressed a crucial provider engagement weakness for many of today’s payers: access to care that affects Star ratings.

Solution Challenge to Opportunity:
Agents were experiencing a high propensity of errors with data keying, leading to an unclean master database. Because errors result in inaccurate or delayed claims payments, auditing and quality assurance (QA) processes were stringent. Our solution implemented non-invasive automation technology and built multiple validation rules to ensure clean entry into the master database.

Prior to automation, there were 17 manual steps in the process queue. HGS reduced manual steps by 70%. We reduced total handle time from 56 minutes to less than 14 minutes, for a greater than 75% savings. For this solution, we deployed our intelligent RPA solution to drive $800,000 in annual savings. Database quality improved from early 90s to >98.5%.

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