Solutions

Solutions powered by SVG logo for hStream platform.
Frame 586 (1)

Quality Manager formerly known as abaqis®

Mitigate risk and elevate your quality of care. Improving both clinical and business outcomes starts with a smarter, more integrated approach to regulatory training, continuing education and quality management.

Learn More

NEW TO THE STORE

hStream Content Marketplace

Connecting you to the Best Content. Access to 75 Partners and 35,000+ Courses in our Industry-Leading Marketplace. Streamline content purchasing, updates, hosting, and connectivity for your organizational needs

NurseGrid Learn

Online store for Clinical Learners. Individual CE Credit and industry products for Clinical Learners are now available through NurseGrid Learn (Beta). Explore our robust collection of courses that provides an unparalleled level of flexibility and choice.

Practitioner Courses

Meet the DEA's new requirement under the Medication Access and Training Expansion (MATE) Act in an online, high-quality and self-paced 8-hour DEA MATE Act course specifically designed for practitioners, including Physicians, PAs, NPs, Pharmacists, Dentists and others.

LATEST & POPULAR

BLOG

CredentialStream named the top credentialing software by G2
REPORT

2024 Annual Report on Medical Staff Credentialing
On-Demand Webinar

State of the Industry: What’s Next for Healthcare Quality & Safety in 2024?
BLOG

Summer 2024's Top Choice in Healthcare Credentialing: CredentialStream
BLOG

HealthStream Executive Briefing: CMS Minimum Staffing Standards: What You Need to Know
Webinar

Clinical Placement for the Future of Healthcare: myClinicalExchange Discussion with CommonSpirit Mt Region and UW Health

< HealthStream Resources

blog

Top Three Challenges for Today’s Health Plans and Tips to Tackle Them (1)

Top Three Challenges for Today’s Health Plans and How CredentialStream's Network Module Tackles Them

January 10th, 2023
January 10th, 2023

Health insurance in America is constantly changing; where it’s being sold, how much it costs, who’s participating in it, what’s covered and so much more! For those Medical Services Professionals (MSPs) tasked with managing a health insurance plan, there’s a lot to keep track of, but thankfully, they don’t have to go at it alone. Read on to learn about the top three challenges for today’s health plans and how Network can help tackle them.


Challenge #1 - Data Management Woes

Typical provider management systems are designed for healthcare systems and medical groups – not health plans. Keeping provider data information up-to-date is a herculean task, and is one that can lead to headaches and a poor experience for your patients and providers if not done properly. If a health plan is working with a solution that was not explicitly designed for their business, there will be setbacks, which can prove costly.


How Network Helps: Health plan-centric data structure

Network was designed specifically for Health Plans. It features a data structure that is completely different from typical provider data management systems. It is built to support the data structure health plans are required to contend with. Reporting within this data structure provides a reliable backbone for operations management.

Fostering data alignment is a critical component of a health plan’s operation, which includes not only credentialing but the ability to manage contracted group and/or provider data submission of rosters, enrollment applications from your contracted entities, and changes/terminations related to providers and their facilities. Network also has the capability to meet federal, regulatory, and state requirements your health plan must abide by.


Challenge #2 - Resource Management

Resource management includes the planning, scheduling, and allocating of people, money, and technology to a project or program. And like in most other industries, finding, training, and retaining staff is challenging, especially in a specialized field like MSPs. If an MSP is working with multiple manual processes or a software solution that isn’t providing any automation or assistance, it becomes very difficult to keep employees engaged and committed to doing their best work. To avoid losing valuable team members, processes should be put in place to support their work and make their day-to-day tasks as efficient as possible.


How Network Helps: Automation tools for various workflows

One of the core pillars of Network is the various workflows available. Each functions as more of an automation tool vs. a checklist of to-do tasks. There are workflows designed to support:


  • Provider relations
  • Delegated credentialing
  • Non-delegated credentialing
  • Network data management
  • Directory updates
  • And, more

These workflows have automation and best practices embedded within, which reduces the amount of manual work an MSP has to do to complete a task. These workflows feature information from our continuously updated content libraries.


Challenge #3 - No Surprises Act

One of the most recent industry regulation changes that payers must work around is the No Surprises Act. The 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 doing so can get expensive. Data from a survey released by CAQH shows that physician practices spend an estimated $2.76 billion a year updating provider directory information for health plans. Considering that most standard physician practices need to submit information for around 20 health plan contracts, it’s clear to see why help is required in order to ensure these health systems can keep up!


How Network Helps: Health Plan Directory management (AKA support for the No Surprises Act)

Network provides access to a variety of workflows focused on directory update support to assist health plans in keeping up with the industry regulations brought on by the No Surprises Act. The content was built to fully support that process so that nothing falls through the cracks. For example, the Network content library has an email that gets automatically sent to providers prompting them to confirm or update their directory information, so that MSPs can then process the proper information within the required time period.


Conclusion

Network was created with the top three challenges for today’s health plans in mind. In the past, the available solutions focused heavily on what healthcare systems and medical groups need, not health plan demands. Network supports the health plan’s success in managing accessibility, quality, and provider networks. Whether an MSP is focused on provider relations, credentialing, or data management, Network can help. For additional insights, watch our webinar: Tackle Top Health Plan Challenges with Network today, or reach out with any questions!

Request Demo