Payers have mountains of data about the providers in their networks, though much of this data is decentralized across various departments and often outdated. With the Interoperability Rule soon raising requirements for provider directories, now is the perfect time to rethink and improve ownership of provider data and provider eligibility monitoring. 

In this post, we’ll provide a framework for refining ownership of provider data and eligibility monitoring in your organization and explore the most common accountability structures we see with health plan clients. 

Provider eligibility monitoring provides real-time insights into billing eligibility criteria, reduces expensive recoupment efforts, improves data accuracy and transparency, and drives operational efficiency across the business. 

Who Owns Provider Data?

Healthcare organizations are famously siloed. The larger the organization, the harder it usually is to execute objectives that require cross-team visibility, collaboration, and automation. The challenges teams face in divvying up ownership of solutions like provider eligibility monitoring include complex organizational structures, poor cross-functional communication, and murky oversight for the big picture. 

Clearly delineating between who owns what for cross-functional initiatives may be the most significant factor in future success. ProviderTrust Agile Coach and Facilitator Becca Hiller offers, “If everyone owns it, no one does. And just because someone owns this, doesn’t mean they are the only one who has to work to make it happen.”

A Framework for Refining Ownership of Provider Data and Insights

What do we have? What do we want? What do we need? 

Hiller offers this simple framework for navigating complex ownership discussions. 

  1. What do we have?
    Start by taking a full inventory of existing accountabilities across teams and roles. Then, map related workflows and include measurements of the time and effort required at each step. 
    • For example: Analyze the workflow of identifying and confirming an active exclusion for a participating provider and then taking the appropriate steps. 
  2. What do we want?
    Design your ideal state.
    • Which workflows could you improve with more data transparency?
    • Where is the manual work that could be automated?
    • Be specific about these goals. For example, instead of “we want more automation across workflows,” use “we want to automate the process of confirming exclusions and license revocations monthly within our Medicare Advantage provider network.” 
  3. What do we need? 
    Compare your existing accountabilities, workflows, and ideal state. Identify the gaps between what you have and what you want.
    • Where should provider data be integrated across systems?
    • Where are we using spreadsheets that create waste and are immediately outdated?
    • What gaps in accountability emerge? 

Two Levels of Strategic Ownership

One practice we have found to work well for this type of initiative is viewing ownership at two levels: value ownership and process ownership. This approach allows for clear accountability for the people completing the workflow tasks and cross-functional accountability at a leadership level.

  1. Value Ownership:
    Value ownership is, most importantly, cross-functional. This owner is responsible for ensuring that data processes meet the big-picture needs of the business. The main hallmarks of value ownership are: 
    • Data accessibility and reporting needs by every team involved
    • Cross-team workflow improvement and optimization
    • ROI and overall quality measurement
    • Leverage provider eligibility screening earlier in the provider lifecycle
    • Align with and contribute to the strategic initiative(s), e.g., interoperability or automation
  2. Process Ownership:
    The teams and people who interact with the provider data, software, and reporting regularly own these accountabilities and tasks (e.g., provider network management, credentialing, and payment integrity).
    • Eligibility criteria and evaluation maintenance
      • Document the eligibility criteria for each LOB or network 
      • Maintain the eligibility criteria
      • Identify new eligibility-affecting data sources
      • Evaluate eligibility criteria regularly
    • Data management and hygiene
      • Document where provider eligibility data enters your organization and which teams need and use that information
      • Ensure internal provider network data is regularly updated to account for terminations and enrollments
      • Document which systems use the provider eligibility data
    • Product interaction/delegation
      • Process provider eligibility alerts
      • Review provider eligibility data (e.g., license & certification verifications)
    • Reporting and measurement
      • Fulfill audit requirements for historical monitoring reports

Three Examples of Effective Provider Eligibility Ownership

We know each healthcare organization has its own needs and challenges. See how some of our clients have organized responsibility for their provider eligibility monitoring across key stakeholders. 

As health plans grow and evolve, it becomes increasingly important to evaluate provider network data processes and ownership regularly. We recommend engaging in this exercise at least every other year to ensure your plan leverages provider data to meet the business’s needs and your teams are not overly reliant on manual processes. To learn more about how continuous provider eligibility oversight can deliver value across your health plan, check out our eBook


What can smarter provider eligibility monitoring do for your plan?

Get the eBook