The following case study is a story of the impact ProviderTrust’s smarter exclusion monitoring can have for clients with large record volumes — in this case, a large health plan with members nationwide. We transitioned a large health plan client from a prior process of needing to verify false positives every month for thousands of providers to our automated, exact-match exclusion monitoring, leveraging our enhanced primary source data to catch exclusions their prior process had never identified.

The Challenge

Our client had been using a potential-match exclusion screening solution when they contacted us to help solve what had become a huge operational challenge for their health plan. Every month, our client would upload multiple spreadsheets to their previous exclusion screening solution, totaling more than 200,000 records of unique providers across 6 lines of business. The system would return any potential exclusion matches that surfaced based on similar name only, across all state and federal exclusion sources for manual client verification and review. 

This tedious and risky process presented significant operational challenges for our health plan client. 

First, every month’s exclusion screen would generate tens of thousands of potential exclusion matches that needed to be reviewed. These potential matches required an employee to go line by line and verify at the primary source whether each exclusion was a match, relying on internal data and unique identifiers in their credentialing or provider data management systems. This process, due to the human verification element for thousands of records every month, left our client exposed to the risk of human error. 

Second, the time and labor needed to properly review and verify thousands of potential matches on a monthly basis were extremely costly. Our client had hired several full-time employees to verify potential exclusion matches every month, and those teammates were typically unable to verify all of the potential matches before the next month’s files were processed, resulting in a growing number of incomplete exclusion verifications.

Third, our client had no internal data enhancement or augmentation strategy around their monitored provider data, leaving their current process of exclusion screening and manual verification exposed to name discrepancies, NPI status changes, and more. After learning about their process, we immediately assumed that our smarter monitoring strategy would identify and verify exclusions that our client had previously missed, and this hypothesis proved correct.

About the Client

Our client is a large health plan based in Boston, MA and is a national leader in providing dental and vision benefits for more than 27 million Americans, while also providing care directly through their growing network of oral health centers in communities around the country. They provide flexible and customized dental solutions for Medicaid, Medicare Advantage, health care exchanges, small and large businesses and to individual members. Their clients range from state governments to leading health plans. They are the largest Medicaid dental program administrator in the U.S.

By the numbers:

  • 240,000+ providers across 6 lines of business
  • 85 oral care locations in 5 states
  • Operating in 32 states
  • 27 million members nationwide

Partnership Goals

  • To successfully transition our client away from a manual, risky process to an automated, risk-free solution. 
  • Deliver our smarter exclusion monitoring solution, confident that our primary source data enhancements would catch exclusions that our client had likely missed previously. 
  • Maintain specific compliance requirements unique to every line of business to ensure compliance in every operation across the health plan.  

How We Helped

  • Implemented our smarter exclusion monitoring across all federal and state exclusion primary sources, delivering an automated solution complete with enhanced data matching to provide the industry’s best solution for exclusion searching. 
  • Automating the exclusion screening process has saved our client hundreds of hours of labor on a monthly basis, which they have since redeployed to other strategic projects.
  • Navigated a tricky transition from manual searching to automated monitoring while keeping specific compliance requirements needed for every individual lie of business (example: SSDMF monitoring for specific populations).

Results

Within just 2 weeks of activating our smarter automated exclusion monitoring across our client’s entire health plan, ProviderTrust delivered:

  • 342 verified, exact-match exclusions
  • 211 of 342 exclusions (62% of total exclusions) verified were identified due to enhanced primary source data, unique to ProviderTrust’s smarter monitoring.
  • More than 40,000 potential exclusion matches auto-resolved, alleviating hours of manual labor for our client.

Final Review

ProviderTrust delivers the most comprehensive and intelligent population monitoring solution for healthcare organizations. This particular challenge was an opportunity to help a large national health plan to achieve compliance in their exclusion screening process by transitioning away from a manual screening process to a smarter, automated solution.

Our approach helped our client achieve full automation, leverage our primary source data enhancements, and maintain compliance requirements across every line of business. We are confident our strategic partnership has helped our client stay compliant automatically and better serve their 27 million members across the country.