By Gevik Nalbandian
Keeping physician credentials and affiliations up to date has been a long-standing source of angst for payers and providers. Research estimates that 2 to 2.5 percent of provider data changes each month, and an estimated 20 to 30 percent of physicians change affiliations each year.
Despite digitization of healthcare, credentialing, contracting and confirmation processes remain stuck in the dark ages, often relying on faxes and phone calls to update physician information, verify employment, or check eligibility. As a result, sluggish manual processes and human error add considerable frustrations for patients, providers and payers alike. A 2018 survey from the American Medical Association found that over half of US physicians say they encounter patients every month with health insurance coverage issues due to inaccurate directories of in-network physicians. It’s also costly. Research finds it costs the U.S. healthcare industry more than $2 billion a year to maintain provider data.
Payers and care providers depend on provider data for referrals, claims, hospital privileging, provider credentialing, payor contracting, and network management. Further, the shift to value-based payment models creates a need for better coordination between payers and their provider networks, particularly around the areas of risk sharing and quality measures.
Provider directories also protect patients by preventing unqualified individuals from practicing medicine and ensuring they are licensed to deliver specialized care for which they hold credentials.
Rather than rely on disparate databases and administrators, who must spend significant time and effort trying to locate and update physician data, why not allow doctors to manage their own credentials and affiliations? Why not make them a steward of their data?
Allowing physicians to proactively manage and verify their information—including credentials, specialties, locations and affiliations, phone number, hours of operation, languages spoken and whether or not they are accepting new patients—would strengthen data quality and diminish the time between data submission and use. This new standard of stewardship and identity management would lay the foundation for enhanced provider engagement and collaboration, accurate claim adjudication and reimbursement, and better patient/member loyalty and experiences.
If we as an industry fail to embrace a new approach to physician credentialing and provider data management, patient leakage, poor referral management and patient dissatisfaction will continue. As organizations look to rebound from Covid-19, the financial fallout of patient leakage is significant—as much as 20 percent of a health system’s revenue each year because patients seek care elsewhere.
So how do we get there? We start by breaking the shackles on central control and move toward a decentralized approach. We leverage smartphone innovation and such technologies as blockchain to make provider information readily available, verifiable, and easy to update.
Decentralized or self-sovereign identity can be a safe, privacy-preserving way for clinicians to validate and share information about themselves with a particular provider. These types of verified credentials could include board certifications, hospital admitting privileges, driver’s licenses, or college transcripts. In this model, each credential is generated by a trusted issuer, such as a DMV which issues a driver’s license. A credential issued by a state university can then be verified by an employer, bank, or other interested party.
Empowering physicians to play an active role in their provider identity could relieve many of the administrative burdens and costs associated with data management and reconciliation. Improving provider directory integrity and reducing the time and effort of keeping the data accurate and up to date, not only reduces the number of out-of-network referrals, simplifies billing, and grows the business, but dramatically enhances the patient and provider experience, while improving care continuity and outcomes. This means patients and their care providers can get answers faster and put that information to use. For example, it’s hard for a doctor to refer a patient to a specialist with a five-week wait time and just as grueling for a patient to wait that long.
Recently I wrote a blog on how consumers can manage their own destiny by controlling their own data and consent declarations. That is only one-third of the equation. The other two pieces include the community of health professionals and the ecosystem required to nurture well-being.
The time for provider data disruption is now. A new model can be established by strengthening identity verification and reducing friction among participants. These are important pillars for payer-provider collaboration and the patient experience.
NextGate is developing new opportunities that will change how the community of health professionals (aka doctors, nurses, pharmacists, therapists, etc.) fundamentally interact with their patients as well as with health systems, clinics, pharmacies, payers and ultimately every entity they have to identify themselves with and share information with. Continue to watch this space in the months to come.
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Gevik Nalbandian is Vice President of Software Engineering for NextGate, the global leader in healthcare enterprise identification. You can reach him at firstname.lastname@example.org.