Provider Management Solutions

Support your providers and members with greater visibility, more effective engagement, and comprehensive reporting tools.

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What does provider management do?

The healthcare industry relies upon provider data to better connect members to services, process payments, manage contracts, and access data for credentialing. It’s the responsibility of provider management to maintain the operations of the provider network in order to ensure those crucial services are seamless and uninterrupted.

However, it can be a challenge to maintain an accurate and up-to-date provider database. Health plans and providers might have to access many different databases for the information they need, resulting in incompatible systems, inconsistent formats, delays in data transfer, outdated information, and higher risk of fraud. This lack of operational efficacy can have serious repercussions for health plans, providers, and members.

Health plans want to serve their members

Health plans want to provide the best services possible and greatest options of care to keep their members happy and healthy. They also want to offer a comprehensive and updated network of providers and practitioners to attract and retain members.

Good provider data management enables these important points of differentiation by promoting:

  • Greater clarity for members when they inquire about the status of appeals, grievances and claims.
  • Detailed information on providers in-network, their location, and plan-recommended specialists.
  • Constant updates on the roster of available providers that are entering and leaving the health system.
  • An easier method of ensuring that every member is assigned to a PCP that is convenient for their needs.
  • Up-to-date details on which procedures and services are covered under existing policies based on network information.
  • A thorough analyses of aggregated provider data to accurately model levels of value-based care.
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Health plans want to work with their providers

Health plans rely on managing good relationships with providers because if they leave to a different health plan, members will prefer to follow them. At the same time, doctors and hospitals are under enough stress in delivering care without having to worry about delays and inaccuracies in information that could cause a patient to register a grievance.

Effective data management can assist in building a positive payor-provider relationship through:

  • Faster and more efficient filing and submission of claims with fewer errors.
  • Automated processes for prior authorizations to avoid delays in specialized procedures and referrals.
  • Faster and more accurate communication over appeals or grievances filed against practitioners.
  • A more efficient and accurate credentialing process.

Hitachi Solutions can help with technology solutions

Microsoft Dynamics 365 is the tool for building a true “provider 360” view of your data and the means to build better relationships with providers.

  • Consolidate all available information into a comprehensive record, pulling details from disparate systems to include the latest details on: Appeals & Grievance, Licensing & Credentialing, Claims history, Contracting, Networks, Clinical Affiliations, Interaction History
  • Automate and streamline lengthy processes, like credentialing and prior authorization, by allowing instant access to different data sets and better management through immediate updates and automated tasks.
  • Foster greater communication through intuitive planning, best practices, and reporting tools that increase engagement and support provider calls and visits.
  • Track the utilization management of the health plan across providers to determine if services are being prescribed appropriately and claims are submitted accurately.
  • Identify trends for rejections, errors, and pain points in order to resolve issues and better map out solutions.
  • Improve the onboarding process through targeted marketing to prospective providers, better insights into contracting and member profiles, and improved outreach to primary contacts.
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How we can help

Hitachi Solutions offers Provider Services as part of our Engage for Health Plans framework. Whether it’s setting up a new Customer Relationship Management (CRM) system or building a user-friendly provider portal, we can walk you through the digital transformation of your business model to develop a comprehensive solution for your provider data management.