When patients walk into a healthcare facility, they bring a wealth of data—demographics, insurance information, previous medical history, allergies, current medications, and more. For healthcare organizations, this information overload can create chaos. If a patient has multiple records across different systems, it can seriously compromise their quality of care. The same goes for providers.
Mismanaged data can lead to adverse patient outcomes and financial losses for the organization. As part of healthcare data management, optimizing healthcare provider data management can help organizations avoid these challenges and improve care delivery. This guide will explore achieving this goal and allowing healthcare organizations to use data management solutions.
Azulity’s healthcare master data management services can help organizations improve healthcare provider data management and mitigate the risks of mismanaged data. Our solution allows you to create a single, accurate, comprehensive view of healthcare provider data to streamline operations, enhance data quality, and improve clinical and financial outcomes.
Importance of Provider Data Management For Healthcare
What Exactly is Provider Data in Healthcare?
Provider data is a comprehensive set of information about healthcare practitioners and organizations. For all providers, a dataset should exist in the databases of all associated organizations and institutions with whom they interact in healthcare operations. In most instances, for individual providers, groups, and institutions, provider data would consist of the names of individuals or organizations’ contact information, such as phone numbers, email, websites, self-service portals, and associated health plans and networks. Provider data in a healthcare delivery setting encompasses vast information crucial to daily operations.
This includes practitioner credentials and specialties, practice locations and schedules, hospital privileges and affiliations, insurance network participation, referral networks and preferences, and clinical performance metrics. Managing this data is complex for a healthcare provider organization due to its dynamic nature. Practitioners frequently update their credentials, change practice locations, modify their areas of specialization, or alter their hospital affiliations. Patients move, get married, and change their health plans. Keeping this information accurate and up-to-date in large healthcare systems with hundreds or thousands of providers and patients is monumental.
The Impact of Inaccurate Provider Data on Healthcare Providers
When provider data is inaccurate or outdated, healthcare providers face significant challenges:
Patient care and satisfaction
Inaccurate provider information can lead to scheduling errors, misrouted referrals, and frustrated patients. This not only impacts patient satisfaction but can also delay necessary care.
Operational efficiency
Healthcare administrators spend countless hours managing and updating provider information. More accurate data leads to wasted time, increased administrative burden, and efficient resource allocation.
Revenue cycle management
Incorrect provider data can result in claim denials, delayed reimbursements, and revenue loss. For instance, an outdated provider’s credentials or network participation status can lead to rejected claims or out-of-network billing issues.
Regulatory compliance
Healthcare providers face stringent regulations regarding the accuracy of their provider information. Non-compliance can result in penalties and reputational damage.
Care coordination
Effective coordination among providers within a healthcare system is crucial in an era of value-based care. Inaccurate provider data can hinder this coordination, potentially impacting patient outcomes and the overall quality of care.
Referral management
Maintaining an efficient referral network is vital for healthcare providers. More accurate data can lead to appropriate referrals, lost opportunities, and decreased patient retention within the system.
Related Reading
- Data Quality Management in Healthcare
- How to Secure Patient Data
- Master Data Management Solutions
- Patient Data Management System
8 Best Healthcare Provider Data Management Software For All Your Needs
1. Azulity: A Leader in Healthcare Master Data Management
Azulity excels in healthcare master data management, offering proven expertise in deploying healthcare data solutions and credentialing across the United States. Their comprehensive platform consistently synchronizes patient, provider, location, and claims data across all systems and departments. Key features include healthcare MDM, provider MDM, reference data management, credentialing, and provider enrollment. Azulity serves healthcare technology leaders – from CIOs and CDOs to VPs of data platforms and credentialing – helping them eliminate the costly problems of fragmented data systems.
2. Modio Health: A Cloud-Based Solution for Provider Credentialing
Modio Health is a cloud-based credentialing and career management solution for healthcare providers and organizations. Modio Health is a physician-owned and operated platform connecting healthcare organizations with qualified providers. Our goal is simple – remove the hassle around job searching and credentialing for healthcare professionals.
Limitations
- The task function could be improved: The platform does not notify when a task has been missed. The required completion date needs to be included.
- Difficulty canceling this service: I am still getting invoices despite notification of cancellation months ago.
- Cannot search providers: It is difficult to find providers through the quick access in the “Documents” tab.
- Reporting: Reports need to be cleaned up before sending. Hospital credentialing and reports could be improved to meet the high standards of the insurance plan credentialing and reports.
3. Availity: Collaborate With Payers to Improve Patient Care
Collaboration for patient care requires constant connectivity. It is essential to simplify how you exchange this information with your payers. Availity makes it easy for payers to work together, from the initial check of a patient’s eligibility to the final resolution of your reimbursement. You need quick and easy access to information about your health plan. With Availity Essentials, a free, health-plan-sponsored solution, providers can enjoy real-time information exchange with many payers they work with daily.
Availity Essentials Pro, a premium, all-payer option, is also available to providers by Availity. Essentials Pro can improve revenue cycle performance, reduce claim rejections, and help capture patient payments. So you can concentrate on patient care, Availity will remain your trusted source for payer information. Providers can integrate HIPAA transactions into their PMS through our electronic data interchange (EDI), clearinghouse, and API products.
Limitations
There needs to be more support for interoperability beyond payer networks. Real-time updates are dependent on provider network connectivity. The free version may lack advanced revenue cycle and claim rejection management features.
4. CredentialStream: A Comprehensive Provider Lifecycle Management Solution
CredentialStream is a comprehensive provider lifecycle management solution that includes everything you need to request, gather, and validate information about a provider to create a Source of Truth to serve downstream processes. It consists of all of the features of Apply, Validate, and Appoint and is powered by Bolt and Stream. Insights provide credentialing analysis driven by industry data, and The Hub allows for organized accessibility to manage the provider lifecycle. These are a few functions of several features of CredentialStream.
Limitations
Credentialing accuracy is highly dependent on data integrity, customization for unique provider workflows is limited, and integrating additional third-party systems is complex.
5. Optum Provider Data Management: A Comprehensive Solution for Provider Data Management
Provider network data management is a comprehensive solution for efficiently integrating provider data, network analytics, contract management (including modeling), recruitment analysis, credentialing, and detailed reporting with interoperability across various systems.
Limitations
Interoperability challenges with non-Optum systems. Extensive setup and maintenance requirements for analytics and reporting. Limited support for non-provider network data integration.
6. Medallion: A Solution for Offloading Clinician Operations
Medallion is the first solution for healthcare companies to fully offload their clinician operations—state license management, payor enrollment, credentialing, and more—in one modern management platform. Since its inception in 2020, Medallion has saved over 100,000 administrative hours for leading healthcare companies like Cerebral, Ginger, MedExpress, Oak Street Health, and hundreds more.
Limitations
Limited coverage beyond clinician operations and essential provider management. High reliance on automated processes may reduce flexibility for custom requirements. It may require additional integrations for broader lifecycle management.
7. Virtusa: A Comprehensive Solution for Provider Lifecycle Management
Virtusa Provider Lifecycle Management (PLM) is a comprehensive provider lifecycle solution that supports provider relationships from network design and onboarding to claims payment, servicing, and contract renewal. It is a unified platform that modernizes all aspects of your complex provider relationships.
Limitations
Complexity in managing large-scale, multi-provider network relationships. High initial implementation and configuration time. Limited flexibility for small-scale operations due to its broad scope.
8. CAQH Core: Improving Healthcare Processes Through Standards and Automation
CORE brings together the industry to accelerate automation and develop processes that streamline healthcare services for patients, health plans, and providers. CAQH, a healthcare organization’s trusted member and provider data source, helps reduce costs, improve payment accuracy, and transform business processes. Improving payment and claim processing systems is essential in an ever-changing healthcare environment. The new and updated CAQH CORE operating rules significantly advance our ongoing efforts to improve efficiency.
Limitations
Implementation can be costly and time-consuming for smaller organizations. It is limited to standard operating rules, with less support for unique, non-standard data. There is also reduced flexibility in integrating beyond core payment and claims systems.
Challenges in Healthcare Provider Data Management
1. The Challenge of Non-Standardized Data Collection Techniques
The healthcare sector needs to be more cohesive, with a standardized approach for collecting and managing provider data. Organizations must determine how to obtain and import the data they need from external sources into their systems. This often leads to a patchwork approach involving disproportionate manual time and effort in sourcing, extracting, and loading data.
When organizations create methods for managing provider data, they apply differing validations, complicating efficient data exchange between systems and organizations.
2. The Problem With Data Quality Definitions
Data quality and integrity refer to how usable data is for specified purposes in its origin state. No standardized definitions for accurate data would allow organizations to assess and improve provider data quality in healthcare. This results in significant quality gaps between providers, such as health plans, and the external organizations that contract with them. These gaps often exist between different iterations of the same data, and organizations unknowingly make costly and redundant investments in cleaning up the same data.
3. The Accountability Gap
While limited federal and state regulatory requirements apply to provider data quality in health plans, enforcement must be more consistent and generally non-applicable to other providers. Individual organizations are responsible for developing and maintaining standards without better regulatory controls. This is particularly troubling given that data science is relatively new to most industries, and the more organizations apply it, the more they find unanticipated systematic faults. In large organizations with the IT resources to practice data management, more data is surprisingly endemic, accounting for as much as 40% of the whole.
Azulity: The Leader In Healthcare Master Data Management
Azulity specializes in healthcare master data management, bringing proven expertise in implementing healthcare data solutions and credentialing across the US. Our comprehensive platform ensures consistent patient, provider, location, and claims data synchronization across all systems and departments. Key features include healthcare MDM, provider MDM, reference data management, credentialing, and provider enrollment. We serve healthcare technology leaders – from CIOs and CDOs to VPs of data platforms and credentialing – helping them eliminate the costly problems of fragmented data systems. Book a call to learn more about our healthcare master data management services today!
What Problems Do Provider Data Management Solve?
Data Accuracy and Integrity: The Foundation of PDM in Healthcare
Outdated or incorrect provider data can lead to billing errors, claim denials, and patient confusion. UnitedHealthcare faced challenges with provider data accuracy across its vast network. They implemented a centralized PDM system to verify and update provider credentials and information regularly. UnitedHealthcare reduced data discrepancies. This led to fewer billing errors and faster claim processing, improving patient and provider satisfaction.
Operational Efficiency: PDM Streamlines Administrative Processes in Healthcare
Manual credentialing, licensing, and enrollment processes lead to delays and high administrative costs. MedExpress, an urgent care chain, adopted Medallion’s PDM platform to automate tasks like state licensure, credentialing, and payer enrollment. This reduced administrative work by over 100,000 hours, accelerated provider onboarding, and helped the clinics serve patients faster.
Compliance and Risk Management: Maintain Regulatory Standards with PDM
Outdated provider information can lead to compliance risk fines and impact patient safety. Kaiser Permanente uses a PDM solution to ensure all providers meet regulatory standards and credentials are up-to-date. This helps them avoid penalties for non-compliance, maintain patient safety, and uphold their reputation in the healthcare sector.
Improved Patient Experience: PDM Helps Patients Find the Right Providers
Inaccurate provider directories can make it difficult for patients to find the right providers, leading to frustration and appointment delays. Aetna streamlined its PDM system to ensure real-time updates on provider directories. This allowed patients to access accurate information about providers within their network, improving their experience by enabling faster, reliable access to care.
Enhanced Interoperability: PDM Improves Data Exchange Between Systems
A lack of smooth data exchange between healthcare networks can hinder care coordination and delay treatment. The Mayo Clinic implemented an advanced PDM system that connects with other healthcare networks, allowing efficient data exchange on referrals, claims, and provider information. This interoperability has improved collaboration with other healthcare providers, reducing treatment delays and enhancing care continuity.
Revenue Cycle Optimization: PDM Supports Financial Stability
Incorrect or incomplete provider data can lead to denied claims and delayed reimbursements, impacting revenue. AdventHealth improved its revenue cycle management by implementing a PDM solution that ensured provider data was accurate for billing and claims. This led to fewer claim rejections, faster reimbursements, and a significant increase in cash flow, contributing to better financial stability.
Network Management: PDM Optimizes Provider Data for Better Coverage
Inefficient management of provider networks can lead to gaps in coverage, affecting patient access to care. Blue Cross Blue Shield of Michigan used PDM tools to analyze provider data and strategically expand its network. By recruiting and onboarding providers in high-demand areas, BCBS increased patient access to in-network care, enhancing service coverage and member satisfaction.
Related Reading
Book a Call to Learn More About Our Healthcare Master Data Management Services
Azulity specializes in healthcare master data management, bringing proven expertise in implementing healthcare data solutions and credentialing across the US. Our comprehensive platform ensures consistent patient, provider, location, and claims data synchronization across all systems and departments. Key features include healthcare MDM, provider MDM, reference data management, credentialing, and provider enrollment.
We serve healthcare technology leaders – from CIOs and CDOs to VPs of data platforms and credentialing – helping them eliminate the costly problems of fragmented data systems. Book a call to learn more about our healthcare master data management services today!