Leveraging Next Generation Provider Data Management Tools to Improve Member Satisfaction 

Accurate and reliable data is the backbone of efficient healthcare operations, facilitating key operations—from claims processing to enhanced member engagement. Yet, for many health plans, managing provider data remains a daunting challenge. Poor data quality leads to inaccuracies, inefficiencies, and regulatory breaches, all of which negatively impact member satisfaction.

Enter HealthEdge® Provider Data Management, a next-generation solution that optimizes provider data accuracy and automation, paving the way for seamless healthcare operations and improved member experiences.

The $3 Billion Problem with Provider Data Management

For many payers, integrating and validating provider data is a complex process that often relies on time-consuming manual processes. Physician practices alone spend $2.7 billion every year maintaining accurate provider directories according to a study from Council for Affordable Quality Healthcare (CAQH). The same CAQH study estimates that streamlining directory maintenance through a single platform could save physician practices at least $1.1 billion annually.

Maintaining an accurate provider data repository is essential for health plans looking to thrive in the competitive healthcare industry. Inaccuracies in provider information trickle down to members in the form of outdated provider directories and other misinformation, causing delays in care access, denials of coverage, and increased friction between health plans, members, and providers.

By combining advanced artificial intelligence (AI) capabilities with real-time data and automation, HealthEdge Provider Data Management offers a purpose-built solution to combat common data challenges and enable health plans to deliver better outcomes and experiences.

The Role of AI in Elevating Healthcare Operations

At the heart of HealthEdge Provider Data Management is advanced AI. By leveraging AI-driven intelligence, the solution enhances provider data workflows in the following ways:

• Data Enrichment: Automatically enriches provider directories, so members only encounter verified, up-to-date records.
• Matching and Merging: Eliminates duplicate records by intelligently matching and merging provider data from disparate sources.
• Prediction and Insights: Provides actionable data insights, helping health plans resolve discrepancies before they create downstream issues.

With AI enabling seamless data management and real-time automation, health plans can deliver the personalized engagement members expect while reducing operational complexity.

How HealthEdge Provider Data Management Enhances Member Satisfaction

HealthEdge Provider Data Management helps payers build a single source of truth for provider information by integrating with existing solutions to streamline data workflows and deliver real-time updates.

Based on our work with health plans so far, we’ve identified 5 key improvements made possible using our advanced provider data management solution:

1. Provide Accurate Provider Directories

Health plan networks are constantly shifting, and providers frequently move to different practices, making it difficult for payers to maintain accurate provider directories. However, member frustration often stems from outdated or inaccurate information listed on provider directories. Incorrect data about provider locations or network status can lead to delayed care, out-of-network visits, and delays in claims processing.

HealthEdge Provider Data Management helps ensure accurate and validated provider information by:

• Implementing 300+ built-in quality checks.
• Leveraging third-party validations, like National Plan and Provider Enumeration System (NPPES) and address standardization.
• Automating real-time updates through APIs and event-based distribution.

2. Simplify Provider Access

Accessible and accurate provider directories are crucial for members looking for timely, in-network care. The HealthEdge Provider Data Management solution supports members in their search, empowering them to confidently schedule appointments and avoid unnecessary hurdles and unexpected bills. By housing provider data within a unified source of truth, the solution helps ensure members find the right provider on the first try.

3. Accelerate Claims Processing

Claims errors due to inaccurate provider data are costly and time-consuming, impacting both members and health plan operations. HealthEdge Provider Data Management automates workflows to eliminate the causes of manual review at their source, helping health plans:

• Avoid claims delays and denials caused by duplicate or incomplete provider records.
• Automate claims-related workflows to enhance payment accuracy.
• Strengthen payment integrity, especially in compliance with regulations like the No Surprises Act.

4. Automate Data Validation 

Instead of spending hours reconciling inaccurate or duplicate provider records, health plan employees can focus on delivering higher-value member-centric services. Streamlining data integration and validation with HealthEdge Provider Data Management allows health plans to reallocate staff resources toward personalized member support, boosting satisfaction and outcomes.

5. Maintain Regulatory Compliance and Transparency

Members and businesses alike value health plans that remain compliant with evolving healthcare regulations. With a robust infrastructure for managing regulatory data requirements, HealthEdge Provider Data Management helps payers achieve:

• Provider directory compliance to prevent regulatory penalties.
• Alignment with transparency-focused mandates, fostering member trust.
• A proactive approach to adapting to new legislative requirements, avoiding disruptions to member services.

A Case Study in Efficiency and Satisfaction with PEHP

Public Employees Health Program (PEHP) serves as a compelling example of the impact HealthEdge Provider Data Management can have. The health program achieved an initial 99.96% success rate in data migration after implementation, allowing them to update large volumes of provider records in near real-time and achieve faster time to value. This also allowed PEHP to reallocate the work of five full-time employees to higher-value assignments.

As a result, PEHP saw an increase in member satisfaction as well as significant cost savings and enhancing operational efficiency. To learn more, read the full case study.

Why Invest in Next-Generation Provider Data Management?

Advanced Provider Data Management is no longer just an operational upgrade; it’s a strategic necessity. Unified and accurate provider data ensures:

• Streamlined operations: Reduced administrative overhead thanks to fewer manual interventions.
• Improved member satisfaction: Better access to accurate and timely care.
• Regulatory readiness: An automated approach to compliance.

These elements collectively position health plans to thrive in an increasingly complex and competitive healthcare landscape.

Get Started with HealthEdge Provider Data Management

Unlock efficiencies, elevate your member satisfaction scores, and align with regulatory standards using HealthEdge Provider Data Management. Contact us to see how we can partner with your organization.