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Health payers occasionally underperform for a variety of
reasons, many of which involve lack of trust with providers.
Fragmented processes and systems along with inadequate
interoperability standards has resulted in excess
administrative cost for payers.
PAYER-PROVIDER
E N G A G E M E N T
Payer-provider communication gap
Poor data transparency
Lack of omni-channel platform for data exchange
Sources Of Provider Dissatisfaction
hours spent by Providers per week
on administrative work
a year is spent on administrative
waste in the US
30-50%
20%
Change health plan, hospital or
group affiliations
Status changes (licenses, sanctions,
retirement)
Health Payers Constant Challenge: Provider Data
Optimizing The Provider Engagement Journey
Robust analytics and intuitive dashboard reporting improve
data quality and derive actionable insights that aid in
outcomes-based decision making
Unlock Value With Optimized Provider Engagement
With effective provider engagement strategies payers can improve health plan performance and quality
scores for challenging measures. CitiusTech works with leading payer organizations in areas such as:
Data Integration
and Interoperability
For 1 Mn member population, every half star
increase in quality score adds an additional
funding of around $50 Mn to the health plan.
$200 Bn
20+
Inaccurate Provider Data
Physicians change address and/or
phone number
5%
30%
Provider Engagement Journey
Contract Management
Execute contracting terms
Repricing for OON plans
Reimbursement agreement
Incentives & P4P for
value-based care
Medical Management
Utilization management
Care & disease management
Care coordination
Prior auth & referral workflow
Quality & Risk Mgmt.
Chart chase for HEDIS & STAR
Risk adjustment / HCC –
MA plans
Care gaps & closure
Clinical data exchange
Network Management
Network & panel management
for contracted providers
Reimbursement for certain products
IPAs / MSOs coordination
Educating provider
Claims & Billing
Eligibility check
Billing & Medical coding
Remittance and check
Adjustments / Reversals
Explanation of payment
Enhanced transparency can ensure better clinical outcomes and greater value throughout the
healthcare system. Health payers must systematically engage with providers to ensure better
cost, care, quality, and revenue outcomes. Improved provider engagement enables interactive
closure of care gaps and allows providers to proactively improve payer quality scores.
Improve Member
Satisfaction
Improve Provider
Experience
Reduce Hospital
Readmission
Improve Risk
Adjustment
Performance
Increase Quality
Compliance
Increase Primary
Care Visits
Digital
Engagement
STARs, Quality & Risk
Management
Enroll & (Re)-Credential
Credentialing – degree,
licenses & affiliations
Coordination with payer / CVOs
Enroll - as participating
Effective management of provider data can lead to improved
provider data directory accuracy, accurate claim adjudication,
claim reimbursement, and overall operational performance
Real-time communication and engagement tools simplify the
way payers and providers interact with each other and enable
a ‘provider-centric’ approach
Analytics & Reporting
Provider Data Mgmt.
Communication
FOCUS ON
PROVIDER NEEDS
Source: Provider directory data management, 2016, Optum
An engaged provider adds an average of
$460K in patient revenue per year.
www.citiustech.com

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Payer-Provider Engagement

  • 1. Health payers occasionally underperform for a variety of reasons, many of which involve lack of trust with providers. Fragmented processes and systems along with inadequate interoperability standards has resulted in excess administrative cost for payers. PAYER-PROVIDER E N G A G E M E N T Payer-provider communication gap Poor data transparency Lack of omni-channel platform for data exchange Sources Of Provider Dissatisfaction hours spent by Providers per week on administrative work a year is spent on administrative waste in the US 30-50% 20% Change health plan, hospital or group affiliations Status changes (licenses, sanctions, retirement) Health Payers Constant Challenge: Provider Data Optimizing The Provider Engagement Journey Robust analytics and intuitive dashboard reporting improve data quality and derive actionable insights that aid in outcomes-based decision making Unlock Value With Optimized Provider Engagement With effective provider engagement strategies payers can improve health plan performance and quality scores for challenging measures. CitiusTech works with leading payer organizations in areas such as: Data Integration and Interoperability For 1 Mn member population, every half star increase in quality score adds an additional funding of around $50 Mn to the health plan. $200 Bn 20+ Inaccurate Provider Data Physicians change address and/or phone number 5% 30% Provider Engagement Journey Contract Management Execute contracting terms Repricing for OON plans Reimbursement agreement Incentives & P4P for value-based care Medical Management Utilization management Care & disease management Care coordination Prior auth & referral workflow Quality & Risk Mgmt. Chart chase for HEDIS & STAR Risk adjustment / HCC – MA plans Care gaps & closure Clinical data exchange Network Management Network & panel management for contracted providers Reimbursement for certain products IPAs / MSOs coordination Educating provider Claims & Billing Eligibility check Billing & Medical coding Remittance and check Adjustments / Reversals Explanation of payment Enhanced transparency can ensure better clinical outcomes and greater value throughout the healthcare system. Health payers must systematically engage with providers to ensure better cost, care, quality, and revenue outcomes. Improved provider engagement enables interactive closure of care gaps and allows providers to proactively improve payer quality scores. Improve Member Satisfaction Improve Provider Experience Reduce Hospital Readmission Improve Risk Adjustment Performance Increase Quality Compliance Increase Primary Care Visits Digital Engagement STARs, Quality & Risk Management Enroll & (Re)-Credential Credentialing – degree, licenses & affiliations Coordination with payer / CVOs Enroll - as participating Effective management of provider data can lead to improved provider data directory accuracy, accurate claim adjudication, claim reimbursement, and overall operational performance Real-time communication and engagement tools simplify the way payers and providers interact with each other and enable a ‘provider-centric’ approach Analytics & Reporting Provider Data Mgmt. Communication FOCUS ON PROVIDER NEEDS Source: Provider directory data management, 2016, Optum An engaged provider adds an average of $460K in patient revenue per year. www.citiustech.com