Why Consumer Success Depends On Business Processes 2/2

3 things to know about the future of provider networks and partnerships

Along with consumers who increasingly have a choice of insurance, a health plan’s business processes can impact the kinds of providers they attract, setting the stage for future relationships in the new alternative payment, value-based world.

Primary care practitioners and specialists may be leery of investing their time and money in new value-based contracts if there is not some indication that it will be easier for them to take new patients, get paid regularly, ask questions and reasonably adjudicate payments for disputed treatments.


Already, physicians—particularly young docs—are proving that they’d rather join a hospital-based network than try to go out on their own if there isn’t a sustainable model as an independent practitioner. There are a significant number of health systems and health system-based physicians participating in affordable, value-based networks with major insurers. But there are also many big hospital systems flexing their market muscle with new physician groups and demanding higher and higher rates—so the presence of high quality, independent physicians is something health plans want to have available as partners.

Figuring out formulas and models for paying physicians fairly will be a long, evolutionary process. But investing in physician- and-member facing business processes could go a long way for a health plan to boost its value proposition and reputation for physicians. There are three parts of this evolution.

One is eligibility. An online, automated workflow engine with centralized data storage can integrate request intakes with maintenance completion. Members get processed faster and, among those looking to see a doctor right way, there isn’t much waiting.

Two, and related to eligibility, is using an XML API framework to aggregate details from different sources and then share that data with physicians practices and other providers. The providers can get more timely information on their patients’ health plans, and spend less time trying to figure out how to figure out the details of the plans, which almost certainly trickles down to their interactions with patients. If it’s easier to work with a patient’s health plan, it’ll be more convenient to spend time developing a relationship with them and help them stay healthy.

The third is the fact that as American healthcare transforms, many payers and providers have feet in both the old and new worlds—manual and digital, fee-for-service and pay-for-value, collaboration and confrontation. The business processes behind all of those old and new paradigms can be harnessed as a bridge between the old and new worlds, leaving flexibility to use the old when practical while embracing the new faster, as an imperative for the future. Consumers are demanding it.

Vicert teams have a range of experience developing online automated workflows, including with completion confirmation and real-time tracking, plus other use cases across disparate systems and business services. We’ve also designed interfaces for health content.

Where are you struggling?

Organizations around the country are at different points in the spectrum of the consumerization transition. Some may be succeeding in claims processing improvement, for instance. but lagging in some of the member experiences leading up the point of medical interventions, such as the digital navigation of provider and treatment options.

Contact us at info@vicert.com to have a conversation about your ideas on this topic and maybe something interesting will come out of our discussion.

Author: Digital Health Team
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