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Next Generation Provider Network Management

Cate McConnell
August 29, 2018

Healthcare organizations are focusing on ways to increase interoperability, improve communication, and streamline operations in order to deliver the best possible care at the best price for members. Managing provider and network services has always been an important piece of health plan operations. In recent years, health plans have been re-imagining their provider relationships as a strategic way to improve their care delivery and member outcomes.

I recently sat down with two of my colleagues at KPMG to discuss these topics in the latest episode of our podcast series, Appian Talks. Todd Ellis, Principal, and Ash Shehata, Principal, US Healthcare Payer Lead for Advisory and Global Center of Excellence, provided great guidance for payers.

One of the main points we discussed was health plans treating their providers as customers. While that may be aspirational, it is possible and it can reduce payer-provider friction around current challenges, such as:

    • Provider recruitment, credentialing, contracting, and site inspections

    • Claims processing and payment authorization

    • Appeals and grievances processes

Treating providers as customers in order to foster the best possible relationship makes sense. Balancing provider options within a plan's network is even more important with the plethora of choices members now face when choosing a health plan.

Why Is Provider Network Management Important?

Health plans work with providers daily to ensure members receive appropriate treatment at the right cost. Whether it's checking if a provider is in-network for members or determining pricing for a given procedure, payers rely on accurate provider information. While providers hold all of that information, it is ultimately up to the health plan to receive, verify, and continuously update it.

The benefits of provider data and network accuracy are far reaching:

    • Improved relationships with providers who find it easy to work with your health plan

    • Increased member satisfaction due to provider coverage and cost transparency

    • Better business outcomes with more timely and accurate claims payments

    • Eliminated risk of fines and reduced Star ratings from government regulation agencies

"This notion of the provider delivery network now being the center of the hub of the contracting capabilities that the payer needs are really emerging to become not just a nice to have, but a must have."

Ash Shehata, KPMG

Changes in Provider Network Management

Health plans have typically had transactional relationships with providers meaning the two parties mainly interacted to exchange claims payments. Now, payers are looking to partner with their providers to achieve improved outcomes on a larger scale for population health.

Another change happening in the industry is that payers are shifting their focus from volume or breadth of providers in their network and are now narrowing their networks to focus on quality, cost, and collaboration.

"It's been proven that as much as 35% in cost savings can be gained by moving to this narrow network."

Todd Ellis, KPMG

KPMG believes that payers are looking for the right technology to support provider and network services initiatives.

Next Generation Provider Network Management Managing Chaos

In the podcast, we discuss two fundamental aspects of provider network management: data and process. Data management is necessary for quality and accuracy maintenance. Process automation can then take place and manage tasks like primary source verification and claims processing. This is nothing new to healthcare payers, who typically have major investments in systems that support these functions.

However, payers may struggle with managing all of these siloed processes.

That's where business process management (BPM) comes in and can help to manage these processes. New technology like robotic process automation (RPA) and artificial intelligence (AI) capabilities can now be injected throughout to speed operations and make more accurate determinations. This intelligent automation approach has payers now moving toward a platform that incorporates this technology without disrupting existing systems. A digital overlay platform like Appian can sit on top of these systems to normalize and standardize legacy systems and support business processes.

"What we're seeing now for those organizations who are better able to actually understand the data that they have that includes metadata and actually embed that data into their BPM processes and approach and even the BPM technology. They're going to be better positioned in the future to be a top-notch organization and I see those organizations excelling and being at the top tier within the industry." Todd Ellis, KPMG

Using intelligent automation technology, payers can begin to view and treat their provider networks as a customer base, improving care quality across the continuum.

Listen to the full podcast below for specific strategic advice from KPMG around provider network management, and contact me to discuss challenges and opportunities for your health plan. You can reach me at

[podcast id="15562265" text="Next Generation Provider Network Management"]

Cate McConnell

Global Industry Leader, Healthcare Payers