Get to Know Provider Network Management
Learning Objectives
After completing this unit, you’ll be able to:
- Identify the main stages of provider network management.
- Explain the common challenges of provider network management and how Salesforce provides solutions to them.
- Describe the key users of Provider Network Management.
Before You Start
Before you start this module, consider completing the following recommended content.
The Need for Effective Provider Network Management
Cumulus Health Plans is a health insurance company that offers a wide range of health insurance products for all lines of business.
While Cumulus is still a major payer organization or health plan, it relies on outdated systems that require a ton of resources to maintain, hindering innovation and efficiency. In particular, it struggles to manage its provider network. Payer organizations are only as strong as the provider networks they build and maintain. To ensure the best care for its members, health plans must attract and retain a deep roster of quality providers that meet member needs and expectations across a number of factors: specialty, location, cost, and more.
Today, effective provider network management goes beyond the simple recruiting of providers, and it forms a critical part of the payer value chain. Not only must health plans bring providers into their networks, they must also provide seamless digital experiences for members and providers alike to complete critical tasks before and after care. To enable value-based care, health plans must be able to evaluate providers with accurate data across a number of factors. And with increased regulatory requirements around access and adequacy, health plans also need sophisticated analytics tools to assess their network as a whole.
That’s where Salesforce’s Provider Network Management can help: It’s an integrated solution for modernizing and improving every stage of the network management process. In this module, we explore the stages of provider network management, the challenges that Cumulus faces, and how Provider Network Management helps Cumulus overcome those challenges at every stage.
The Provider Network Management Lifecycle
The key stages of provider network management are Recruiting, Credentialing, Contracting, Onboarding, and Ongoing.
This table introduces the goal of each stage.
Stage |
Goal |
|---|---|
Recruiting |
Identify and recruit prospective providers. |
Credentialing |
Collect and verify provider credentials. |
Contracting |
Create, negotiate, and sign provider contracts. |
Onboarding |
Set up new providers to successfully participate in the health plan. |
Ongoing |
Keep providers engaged and successful. |
Provider Network Management provides distinct experiences for different users.
For internal users, it’s easy to set up applications and dashboards for managing provider relationships, the provider network, and internal operations.
You can have a health plan show a recruiting home page that provides key data, actions, and records for its recruiting specialists.
To serve end users associated with the provider organization, health plans can easily develop provider portals, powered by Experience Cloud. These portals allow providers to self-serve on key tasks across the network management lifecycle, such as submitting applications and uploading credentialing documents.
Challenges in Provider Network Management
With the key stages in mind, let’s take a look at common challenges in provider network management. This table lists some problems Cumulus currently faces.
Problem |
Description |
|---|---|
Slow processing times |
Manual processes and poor communication experiences create provider friction and slow turnaround times at all stages. On average, it takes Cumulus 3 months to execute a contract for a new provider. |
Poor data quality |
Cumulus’s provider directories are error-prone, with duplicated and disconnected data the norm. These errors have downstream implications on other key payer operations, such as claims, utilization management, and care coordination. |
High overhead costs |
Cumulus spends extensive resources simply maintaining its existing provider directories, due to the disparate data sources and complexity of its network. Cumulus must constantly expend resources to meet regulatory requirements and avoid violations and fines. |
Low provider satisfaction |
Due to disjointed processes and lack of status transparency, providers are increasingly dissatisfied with Cumulus’s network management solution. Many existing providers are opting to leave the network knowing that there are better experiences available. And Cumulus is finding it difficult to recruit new providers who expect far more self-service and automation. |
Low member satisfaction |
Provider relationships greatly influence member relationships. For health plans like Cumulus, member relationships are only as strong as the network that enables them. Moreover, Cumulus members struggle to search for providers based on unique health needs, resulting in a lower quality of care. |
Faced with these major issues, Cumulus decides to implement Provider Network Management. After implementation, providers can easily join a network through seamless recruiting, credentialing, and contracting applications. They gain visibility into their application process and can manage documentation and communication digitally via self-service portals.
Members can search for providers based on their unique health needs, and have comprehensive care options with high-quality physicians.
Cumulus Health Plans soon sees the following benefits.
- Increased provider satisfaction
- Increased member satisfaction
- Lower service and support costs
- Faster case resolution time
- Increased agent productivity
Meet the Users
Now that we have an idea about the key benefits of Provider Network Management, let’s meet some important users and see how they use it.
Recruiting
Greg Lawson is the Provider Network Director at Cumulus. One of his most important jobs is to analyze the existing network and identify potential providers to fill key network gaps.
Greg starts his day with his dashboard that’s powered by CRM Analytics. He uses the dashboard to produce sophisticated reports that monitor adequacy and develops a list of high-value provider targets.
From there, Cindy Singh, a marketing and recruiting coordinator, takes over.
She adds Greg’s list of targets to a provider recruitment marketing campaign that automates outreach and checks interested providers.
One of the targets of her campaign is Dr. Leila Zamadi, a highly regarded cardiologist who fills in geographic and speciality gaps in Cumulus’s provider network.
Upon receiving a personalized email, Dr. Zamadi decides to learn more about Cumulus and its provider network. Following an email link, she fills out a provider registration form from the provider portal.
Back at Cumulus, Cindy immediately receives notification of Dr. Zamadi’s interest. Cindy now has actionable data to conduct further outreach and steer the practice into a more formal recruiting process.
The next day, Cindy conducts a call with Dr. Zamadi, which ends with Dr. Zamadi accessing the self-service provider portal where she completes her application. She soon receives a welcome email that fills her in on the next steps and invites her to set up a profile in the portal.
Credentialing
After the submission of Dr. Zamadi’s application, it’s time for Derek Brooks, Cumulus’s credentialing specialist, to enter the picture.
Derek begins his day by receiving a provider roster, which includes several new physicians, including Dr. Zamadi. To start the credentialing process, he initiates a work guide that the implementation team designed using Flow Orchestration tools.
Derek’s job is made much easier thanks to the Provider 360 view, with all of Dr. Zamadi’s application information automatically appearing on her account and case records. Provider Network Management also seamlessly integrates with Cumulus’s preferred third-party credentialing service. So Derek quickly receives official verification of all Dr. Zamadi’s professional qualifications.
Throughout this process, the provider portal keeps Dr. Zamadi informed of her status and allows her to easily submit any additional documentation.
Contracting
After Dr. Zamadi’s credentials are verified, it’s time to work on the fine details of the contract. Enter Connie Madison, a contracting specialist at Cumulus.
Thanks to Provider Network Management’s contracting tools and workflows, Connie swiftly drafts a contract document. She uses a predesigned template that also incorporates clauses and reimbursement terms specific to Dr. Zamadi’s specialty and background. The contract then routes to Connie’s manager for approval. Her manager can easily review and suggest any needed changes directly from the approval request.
After getting manager approval, Connie digitally sends the contract over to Dr. Zamadi’s office for review. Following some negotiation, they reach agreement on key issues such as prior authorizations, reimbursements, claims processing, rates, and disputes.
Versioning capabilities make it easy to revise any aspect of the contract and seek any additional approvals. When the contract is ready to sign, Salesforce provides integration with Cumulus’s preferred electronic signature solution.
Onboarding and Beyond
Provider Network Management does not end with signing of the contract, though. After Dr. Zamadi signs the contract, Cumulus assigns a provider coordinator, Colin Sparks, to guide her on a highly personalized onboarding experience that sets her up for long-term success.
As part of this journey, Colin assigns Dr. Zamadi and her office team learning trails. The learning trails reflect the health plan’s culture and ensure compliance and unified processes across the entire provider network.
After onboarding is complete, Dr. Zamadi and her team can always reach out with any questions as the provider portal enables fast, in-context communication, empowering them to resolve issues efficiently.
And Dr. Zamadi and her team have more time to focus on delivering the highest quality patient care, a win-win-win for everyone involved: Dr. Zamadi, Cumulus Health Plans, and its members. The provider network management team at Cumulus greatly benefits from an array of tools that increase the efficiency and effectiveness of their primary jobs to be done.
In the next unit, we explore provider recruitment and find out how Provider Network Management tools support the process.
Resources