Exchanging data between healthcare providers and health plans/payers has been a contentious subject throughout the 23 years I’ve been working in healthcare IT. Physicians have long expressed dissatisfaction with the time they and their staffs spend interacting with health plans. And all the federal and state mandates laid on providers and health plans over the past decade have not improved matters.
What is Provider Data?
Provider data, simply put, is information about individual providers, groups of providers and institutions—who or what they are, how to access them, the services they provide, the health plan networks or products they participate in and other important attributes. These data facilitate everyday business and regulatory transactions, or “use cases,” such as claims processing, credentialing, contracting and licensing, and allow patients to find and access care. While provider data is conceptually straightforward, it is incredibly complex to standardize, manage and maintain.
Which Providers & Health Plans Exchange Data?
3. Contracting including Practice and Provider Directory
4. Pharmaceutical Formularies
7. Treatment Plan Compliance Monitoring
8. Quality Measures
As Mark Martin notes in Leveraging Technology to Enhance Payer-Provider Relationships, “the key is to forge pathways where these two spheres of data (provider and payer) can overlap and be leveraged to benefit both stakeholders.”
Critical Provider Data Use Cases and Common Data Needs
Some Background Materials