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Payors are still assessing the impact of COVID-19 pandemic on their business model, operations, and profitability but the consensus is that it will be enduring and irreversible.

Major first and second-order implications of COVID on Payors include (not intended to be exhaustive):

Unemployment-Driven Changing Insurance Mix. An unemployment spike could prompt a major drop in commercial insured lives as we could see over 40 million jobs lost in the next six months in the US. Payors who are heavily weighted towards commercial lives – particularly those with a greater portion of small group lives that are more likely to be impacted by the recession – are at risk of seeing significant membership loss. On the flip side, those with exchange and/or Medicaid businesses could see a heavy influx of members this year. For those, the keys to success will be capturing those members as they shift, and also finding a way to be profitable in those segments. Regardless of how you read the above output, its impact is significant.

Surge in Care Needs. While there has been a material drop in elective and routine care over the past couple of months, buoying near-term profitability, Payors should expect a surge in healthcare sought in the coming months as states reopen and infection rates begin to subside. This surge will likely be attributable to both previously scheduled care that was postponed (e.g. elective procedures) and incremental/urgent care needed by members with chronic conditions who were unable to receive the high-touch maintenance that they do under normal circumstances. While we believe that it is safe to assume that there will be an uptick in care needs, it’s challenging to estimate the exact amount. 60 percent of primary care Providers think their patients could incur a preventable illness because of limited care access. Another 38 percent said non-COVID deaths could occur after the pandemic because of delayed care.

Evolving Member Expectations. This crisis is changing how care is delivered and will undoubtedly change how members seek care. Telehealth benefits will become increasingly commonplace and utilization – historically low - will sustainably increase as a greater number of members begin to realize that virtual care is an appropriate substitute for in-person, routine care. There will likely be greater member expectations on being able to find the care they need, when they need it and using the modality they need it through. Moreover, members will likely expect Payors (and Payors will want to) to help facilitate the delivery of greater care in the home.

Evolving Provider Expectations. This crisis has had a dramatic, disproportionate impact on Providers of all shapes and sizes. There is likely to be a great deal of Provider consolidation due to several factors. We anticipate Providers expecting Payors to increase fee-for-service rates, make advance payments, renegotiate certain contractual terms that have a material impact on accounts receivable, and day’s sales outstanding metrics among other things. We believe that Providers will gravitate towards Payors that are easier to work with and with whom there are fewer administrative hassles. In addition, we expect that providers will increasingly seek out payer arrangements that entail lower member out-of-pocket expenses and subsequently bad-debt. More broadly, there will likely be an acceleration towards value-based arrangements given the financial weaknesses surfaced by the pure fee-for-service model and the deleterious impact COVID has had on Providers that derive a lion-share of their revenue from fee-for-service arrangements.

Possible Provider Network Implications

How do we expect the composition, quality, and structure of Provider networks to change as a result of the COVID crisis? While challenging to forecast, we have developed a couple of hypotheses on how networks could change and what network managers could face – this is not intended to be a fully exhaustive list.

Changes in Provider Access Points. Smaller independent physician groups are likely to either close (briefly or fully) or be sold to larger organizations. As this occurs, depending upon the nature and intent of the organizations, Payors should expect network access challenges and potential contract renegotiations along with all of the enormous provider data updates that accompany them. Overall, health plans could experience member disruption and corresponding increase in inbound member complaints.

Contract Renegotiations. Separate but related to the above point, Providers will likely revisit contract terms and seek ways to renegotiate rates as well as non-financial terms that impact their ability to collect cash and collect it quickly. We expect surviving Provider organizations to emphasize wanting to minimize the likelihood of denials of all kinds

Value-Based Arrangements. There may be a movement towards value-based arrangements. Surviving Providers will likely start to insist on tying a greater deal of their revenue to value-based arrangements to blunt the future impact of crises of this kind?

How Santech can help Payors

As member and Provider expectations change dramatically following this pandemic, Payors will need to react accordingly. Many sources of member and Provider friction – exacerbated by this crisis – are rooted in provider data management.

Payors that invest in cost-effective capabilities that allow them to manage their network data more effectively can deliver incredible value to members and Providers alike. A Provider data management system that allows Payors to ensure that they have the most current information attached to all relevant contracts will deliver the following sets of value:

●     Improved provider handling through accelerated provider payment and denial minimization. Payors that more effectively manage their network data not only will be able to reduce the administrative burden their network partners face in working with them but can also use this capability – and its ability to minimize the standard claims back and forth that takes place – as a bargaining chip in rate negotiations that are more likely to arise in the coming days.

●     Improved Provider Communication. As Payors may have different programs, incentive needs etc. as per different events, which need to be communicated to specific groups of Providers (by Network, by region, by group or by Specialty), a robust integrated communication will ease out the challenge by helping users create and configure communication templates for event-based triggering.

●     Provider Self-Service. Most Providers will be short staffed from the admin viewpoint in the office and will be impacted on their ability to send faxes, mails or phone calls (make/receive) for changing credentials, services and office hours. Having efficient self-service capabilities will be helpful for both Payors and Providers. It will enable Provider staff to manage their information data elements in the system and consequently Payor staff could validate the same.

●     Member Satisfaction. Payors that more effectively manage their network data are less likely to have dissatisfied members that are struggling to find in-network Providers and – in the worst-case – visit a Provider thinking they’re in-network when they are not. A failure to effectively manage network data doesn’t just manifest at the beginning of a members journey to find care, but can make for a complicated and overwhelming post-care experience that leaves an indelible negative mark on the member, dramatically reducing the likelihood that they will be retained and the likelihood that they will serve as a positive referral source (i.e. negative net promoter scores).

●     Fewer, Smaller Penalties. CMS levies large fines against Payors who have inaccurate Provider directories. CMS doesn’t want members to have difficulty finding care, so Payors that invest in capabilities that minimize the likelihood of this will likely face fewer penalties.

●     Operational Efficiencies. Payors traditionally spend a lot of resources on trying to ensure that their Provider data is up to date, however, these approaches tend to be manual and not technology-optimized.

The COVID-19 pandemic, a global nightmare that has hit the U.S. especially had grim statistics that speak volumes are indicative of, so to do the life-threatening challenges that overburdened healthcare organizations are now facing as the COVID-19 runs its course. Hospitals are packed beyond capacity with patients now needing to be treated at emergency makeshift facilities. And while Providers on the front line deal with life-threatening situations, this crisis will no doubt impact how Provider and Payer organizations must react to all the more critical demands to credential Providers and enroll them into health plans.

Although working to ensure that the care and treatment of victims of this pandemic is now paramount, ensuring that Providers and Provider organizations get timely and accurate reimbursements must also be addressed. The bulk of the burden of these administrative challenges will almost certainly fall on the shoulders of Payers’ and Providers’ administrative operations.

With many medical professionals now working 24x7, emergency patient admissions are increasing at unsustainable rates that are causing severe shortages of Provider staff while also jeopardizing the safety of our healthcare professionals. There is now an exploding demand for additional Providers that are and will be sorely needed to fight this and future recurrences of this type of crisis. A spotlight will therefore almost certainly be placed on ensuring an organization’s ability to onboard, credential and enroll Payers into plans is up to the task. Payers will also be facing similar challenges, which will include the ability to quickly build and maintain quality networks. Unfortunately for many Provider and Payer organizations, there is a reliance on infrastructures and business processes that are outdated, difficult to scale and already posing operational challenges that this pandemic will only further worsen.

These are unprecedented times for Provider and Payer organizations, which will require more efficient and timely enrollment, privileging, credentialing and network management capabilities. This Pandemic will almost certainly be a driver that will require organizations to modernize their systems and business processes to better ensure readiness in the event of future similar crises.

Fortunately, in the short term, CMS has made several announcements regarding the lifting and loosening of various regulations to allow Provider and Payer organizations to better deal with these unprecedented times. Examples of COVID related guidance include temporary leniency for compliance regulations and facilitating timely if not immediate reimbursement of funds to Providers and Provider organizations, providing out of state license to Providers, and postponing practically all steps that slow down critical processes. Payers and Providers should therefore start to proactively enhance, streamline and strengthen Provider management capabilities wherever possible.

Santech Is Ready To Assist

Santech stands at the ready to assist customers and prospects determine how best to face these unprecedented challenges. By appropriately leveraging technology, resources, and subject matter expertise to minimize, automate or eliminate inefficient processes while also streamlining enrollment, privileging, and credentialing capabilities.

Santech remains committed to continue working with healthcare organizations at their pace and convenience as it understands what they’re going through.

Jazz great Charles Mingus once noted that “anyone can make the simple complicated—what’s really creative is making the complicated awesomely simple.” Mingus might have been talking about music, but he also summed up the lengths that dental providers and insurance companies now go to just to execute a simple communication transaction.

Almost any query a payer has for a provider, from a request for backup credentialing information to confirmation that directory data is current and accurate, routinely requires a wearying round of phone calls, emails, faxes, and website checking.

It’s a huge burden on the dental provider’s time and resources, but no longer an insurmountable one. Many dental organizations are making the ingenious move to let automated tools do all this “talking” instead, processing unlimited volumes of payer requests at breath-taking speed.

Still, as efficient as these tools are, it’s essential to keep in mind that they supplement rather than supplant human interaction. With that, let’s delve into the top communication tactics to take with insurance companies in the year ahead, aided by provider data management technology.

Catalog Your Insurance Company Contacts

This can’t be said enough: dental organizations that fulfill requests for information in a consistent, structured manner are the ones that insurance companies want to deal with. With so many dental providers to reach out to, there’s never going to be one dedicated person at an insurance company just waiting to receive and process information from your practice. So, don’t throw your information out there thinking that people will have the time and inclination to extract from it what they need.

Instead, take the lead in making information gathering and processing as simple as possible for insurance companies. Begin by cataloging every health plan you participate in. Then include the insurance company rep’s contact information for each plan; very often, you may have more than one rep for different functions such as credentialing and provider directory updates. Be sure the rep and his or her role is clearly distinguished to avoid wasting time reaching out to the wrong person. Lastly, include each provider that is associated with the plan.

Centralize and Standardize Communication

Obviously, the above tactics are only effective if everyone follows them, so make sure that your staff have the insight to do so. Designate a single, central location from which to manage communication with insurance companies. This will be the same place you keep the above information about health plans, plus all your provider enrollment, credentialing, and directory data.

There are provider data management systems that store all this information. Those that are internet-based or cloud-based will offer a true centralized “hub” for multi-location practices. Even more, they can automate much of the work involved in fulfilling insurance requests. This includes “one and done” data inputting that automatically populates related data fields across different forms; duplicate record scrubbing; and the ability to send insurance companies documentation right from the provider data management system itself.

Note that once such capabilities are in place, dental practices no longer feel they have to save up batches of enrollment, credentialing, and provider directory tasks to process. This isn’t a recommended best practice, either. Insurance companies don’t want to process a bulky batch of requests any more than you want to tackle a separate new one every day.

Close the Loop

When you’ve completed a transaction, make sure both you and the insurance company consider it closed. This will be helpful on a couple of different levels. First, it will keep everyone in your dental practice or services organization on the same page about where your provider data activities stand with each insurance company. Second, it will serve as an evidence trail for proving that your organization did indeed complete or otherwise comply with an insurance company’s request. So if you’ve sent updated information on three different providers, or a copy of a provider’s license, or anything else the insurer requested, ask for confirmation that it was received. Then make note of this confirmation.

Of course, as we know, communication with payers never really ends. Just as soon as a directory is updated or provider is credentialed, it will be time to renew the information for both. With that, here’s one last tip: make sure your provider data management system has automatic reminders built in for upcoming expirations. Such a system, paired with the tactics above, can make the business of practicing dentistry much simpler. Make that awesomely simpler

Santéch will join a number of industry innovators leading the charge for change in the payer space at the upcoming AHIP Institute & Expo on June 7th through June 9th in Austin, Texas. The company will unveil its "Agile Provider Network" model for payers to quickly and efficiently create their care networks and forge successful provider partnerships, at the Santéch booth #1239 and in a special session for the payer C-suite and leadership teams.

"Payers are rightfully wondering how they can better manage provider data and provider relationships in this new era of consumer-driven healthcare. We are looking forward to helping them discover the answer—the 'Agile Provider Network'--at AHIP," said Neeraj K. Sharma, Chief Operating Officer at Santéch Solutions.

How a "Cool Vendor" is changing network management for the better
Santéch was recently included in the Gartner "Cool Vendors in Health-Value Management for U.S. Healthcare Payers, 2017" report by Bryan Cole, Jeff Cribbs, Brad Holmes, published April 11, 2017.1 The report offers U.S. healthcare payer CIOs an in-depth look into the innovative administrative, customer engagement and analytics capabilities that enable payers to enhance their value to consumers and customers, and disrupt problematic industry norms.

One of the worst of these entrenched norms is an outdated, very fragmented way of managing networks. Data is segmented into different departments, with multiple systems and departments managing networks, often inconsistently. This flawed approach hinders rapid expansion into new markets and is the cause of equally fractured relationships with providers.

To that end, Santéch is on a mission to make provider and network management infinitely smarter. The company's platforms (I-Network, I-Enroll and the patent-pending I-Net Xchange) free payers and providers from tedious, duplicative management of important provider data, and provide a modern infrastructure that fosters mutually profitable relationships and care networks.

Payers, in particular, leverage the I-Network enterprise platform as a single version of truth to seamlessly manage all aspects of their provider networks--including onboarding, credentialing, contracts, and updating provider directories. Both payers and providers use I-Net Xchange to seamlessly relay data to each other, preventing the duplication of provider data and improving its quality.

Most importantly, Santéch's platforms consolidate and streamline interactions between payers and providers and allow greater collaboration—all essential ingredients for successful payer-provider relationships in an era of healthcare increasingly driven by consumer choice and preferences.

Learn more about the Agile Provider Network 

Santéch will present the interactive session: "The Agile Provider Network: Reinventing Network Management and Provider Relations for Today's Consumer-Driven Health Care" at AHIP on June 8th, from 6:00 to 6:45 p.m. at the AHIP Presentation Theater in the Exhibit Hall. The session is geared to payer executives who seek to create profitable networks and recruit qualified providers in a fraction of the time it currently takes. It will be led by Neeraj K. Sharma, Santéch COO, and Bert Fajardo, Santéch VP of Strategy and Solutions.

For a sneak peek at  "The Agile Provider Network" approach, download Santéch's free guide on the topic here.

About Santéch 

Founded and managed by healthcare specialists, Santéch offers innovative solutions to payers, practices and health systems to transform their provider and network management capabilities. Built for scalability and high performance, our enterprise-caliber solutions are designed to meet the needs of small, midsize and large organizations. In 2017, Santéch was named a Gartner Cool Vendor in Health-Value Management. Santéch is a Delaware Corporation headquartered in Oxnard, Calif. with offices in California and New Jersey.

Santech is proud to announce its inclusion in the Gartner "Cool Vendor" list in the Gartner " Cool Vendors in Health-Value Management for U.S. Healthcare Payers, 2017" report  by Bryan Cole, Jeff Cribbs, Brad Holmes, April 11, 2017.

The report offers U.S. healthcare payer CIOs an in-depth look into the innovative administrative, customer engagement and analytics capabilities that enable payers to enhance their value to consumers and customers, and disrupt industry norms.

"We are delighted to be included and recognized in the Gartner Cool Vendor report, and believe it further validates that Santéch's platforms are replacing outdated provider management with a smart, agile technology and philosophy," said Neeraj K. Sharma, Chief Operating officer for Santéch.  

On a mission to make provider management better

Santech's platforms (I-NetworkI-Enroll) and the patent-pending I-Net Xchange are disrupting the Provider Data Management space for payers and providers by enabling organizations to build the modern infrastructures needed to support today's payer-provider partnerships. For example:

  • Payers leverage the I-Network Enterprise Platform as a single version of truth to seamlessly manage all aspects of their provider network, including on boarding, credentialing, contracts and updating provider directories.
  • Provider Groups and Hospitals rely on I-Enroll to manage their providers' credentials and documents.
  • Payers and Providers use I-Net Xchange to seamlessly relay data to each other, preventing the duplication of provider data and improving its quality, and strengthening these important relationships in the new era of consumer-driven healthcare.

With a laser focus on provider data, Santéch possesses a deep understanding of the nuances that surround how organizations process and rely on provider information. Pairing this expertise with Santéch's open architecture allows its platforms to be flexibly tailored to meet the payer organization's specific business needs or seamlessly integrate with the payer's existing infrastructure.

In turn, this enables real-time data exchanges with outputs that can be consumed by incumbent payer care management, financial and quality IT systems. The platforms make it possible to consolidate and streamline interactions between payers and providers through greater collaboration, an essential ingredient for successful payer-provider partnerships.

Learn more about the Agile Provider Network

Santéch is an exhibitor and presenter at the 2017 AHIP Institute & Expo in Austin, Texas, June 7-9. Visit Santéch at Booth #1239. Additionally, Santéch's interactive session "The Agile Provider Network" will take place June 8th from 6:00 p.m. to 6:45 p.m. at the AHIP Presentation Theater in the Exhibit Hall. The session is geared to payer executives who seek to create profitable networks and recruit qualified providers in a fraction of the time it currently takes.

For a detailed look at this methodology, download the Santéch white paper "The Agile Provider Network: Re-inventing Network Management and Provider Relations for Today's Consumer-Driven Healthcare."

Required Disclaimer

Gartner does not endorse any vendor; product or service depicted in our research publications, and does not advise technology users to select only those vendors with the highest ratings or other designation. Gartner research publications consist of the opinions of Gartner's research organization and should not be construed as statements of fact. Gartner disclaims all warranties, expressed or implied, with respect to this research, including any warranties of merchantability or fitness for a particular purpose.

About Santéch

Founded and managed by healthcare specialists, Santéch offers innovative solutions to payers, practices and health systems to transform their provider and network management capabilities. Built for scalability and high performance, our enterprise-caliber solutions are designed to meet the needs of small, midsize and large organizations. Santéch is a Delaware Corporation headquartered in Oxnard, Calif. with offices in California and New Jersey. Visit us at www.mySanté

Health insurance companies struggle to quickly, efficiently, and cost-effectively create their care networks-The very products they depend on to stay in business. Almost all of the challenges are rooted in an outdated, very fragmented way of managing networks. Data is segmented into different departments. Multiple systems are used for different network management functions. And networks are siloed off into different systems. Not surprisingly, such a flawed system is the cause of equally fractured relationships with providers. It also hinders rapid expansion into new markets.

This guide shines a light on a more productive (and greatly simplified) way to create and manage the kind of care networks both providers and consumers want to be in. Readers will walk away with a confident understanding of how to replace their fragmented, disorganized network management with a centralized and enterprise-wide platform recognizable through four essential characteristics. Such a platform:

Houses a seamless collection of core business functions that work interdependently together

Makes all networks and network-related data visible

Is provider-inclusive and integrates network management with other data and systems inside and outside the payer enterprise

The result is nothing less than an overdue reinvention of network management and provider relations for today consumer-driven healthcare.

Click here to download the whitepaper.