Health Systems Face Many Challenges Offering Health Plans, CredentialStream and Network Can Help

Just as technology is always changing, so is the way health systems are run throughout the US. Years ago, a health system would simply have been defined as a collection of hospitals. And while that may still be true, today there’s much more to a hospital system, as it has expanded to include a wide array of people, resources and healthcare services.

The ongoing changes in how health systems function means Medical Service Professionals (MSPs) and Credential Verification Organizations (CVOs) need reliable tools to successfully support a laundry list of requirements that includes managing multiple care settings, provider enrollment, corporate insurance, malpractice underwriting, quality, OPPE/ FPPE, network management and health plan credentialing. In this article, we’ll go into the trends and challenges of health systems offering health plans (also known as provider-sponsored plans or PSPs), along with information on how technology can be leveraged to address the most pressing needs.

Payer-provider convergence

According to PwC, as of this writing, 50 percent of U.S. health systems have applied, or plan to apply, for an insurance license. This trend can be linked to the emergence of the Affordable Care Act and the move away from traditional fee-for-service to value-based care. Many feel that the rise of provider-sponsored plans (PSPs) is a good thing, as PSPs have many assets they can leverage for success including: quick and reliable access to claims and clinical data, strong brands and customer loyalty, and an ability to innovate relatively quickly. PSPs also tend to have access to newer technology to help them provide superior customer and provider experiences. But despite the many advantages of PSPs, health systems face many challenges when offering health plans.

Top Challenges for Today’s PSPs

While rising health care costs seem to be the largest challenge for patients, providers, and payers alike, payers have to deal with other issues such as:

• Attracting new group and individual members
• Moving beyond only selling major medical products
• Uncertainty over health care reform
• Compliance with industry regulations
• Consumer education/understanding of coverage and costs
• IT/system integration
• Increased competition
• Provider shortages
• And, more!

According to Michael Sousa, VerityStream President, “It’s become a strategic imperative for many health systems to begin offering health plans, but as you can imagine, it presents a wide range of new challenges because these health systems now need to develop and manage their own physician networks and payer credentialing processes.” To date, there really aren’t many solutions that fully equip a health system to also serve as a health plan because it’s a relatively new, emerging requirement.

There are also new industry regulations payers must contend with like the No Surprises Act. This Act states, that if you’re a health plan, have internal health plans, or contribute provider information to a health plan, there are four compliance tasks you must adhere to:

• Provide an accurate public-facing provider directory
• Verify the provider directory data at least once every 90 days
• Update the provider directory within two business days of a provider's information change
• Respond to inquiries regarding the provider or facility’s network status within one business day (in-network or out-of-network)

That’s a lot to keep track of and it can be especially costly. In fact, data from a survey released by CAQH has shown that physician practices spend an estimated $2.76 billion a year updating provider directory information for health plans. What’s more, the standard physician practice must submit information for 20 health plan contracts in differing formats and on varying schedules for each plan. With all this in mind, it’s clear to see a comprehensive solution is needed to tackle the challenges plaguing health systems offering health plans.

How CredentialStream and Network Can Help

CredentialStream and Network were created to help tackle some of the top challenges health systems face when trying to offer health plans. Health plans have contract obligations to meet and compliance regulations to abide by, and since typical provider management systems were not designed for health plans it can lead to poor experiences for patients and provider members. Network directly address payer needs in terms of credentialing and onboarding practitioners. It’s a fit for any payer – whether that be a health plan that operates in a health system or an independent health plan.

With Network, both credentialing and onboarding are automated, saving time and increasing accuracy. It also provides a consolidated single source of data that’s reliable, making delivering things like network adequacy and accurate provider directories possible.

In terms of the No Surprises Act, there are three easy to use tools with Network that can help health plans maintain compliance:

Notifications

Notifications can be used to create an automated message every 90 days that reminds providers to verify their directory information.

Workflows

Workflows can be used to create a simple checklist that includes a timeline that providers need to adhere to when reviewing their directory information and linked to Notifications.

Surveys

Surveys can be used to request providers to attest to the accuracy of their directory information.

As health systems with health plans become more popular, and PSPs become the norm, it’s vital to have a solution in place that will foster productivity, improve accuracy, and offer reliability. Network is how MSPs can stay ahead of the curve. To learn more, be sure to visit CredentialStream's Network web page. And if you have any questions or want to schedule a demo, we're always here to help, simply reach out!