The accurate and timely identification of health care providers is vital to managing current costs and avoiding a cascade of costs in future record transactions.

Can you offer any client any combination of contracted provider networks applied to defined geographic areas, including or excluding specific specialties?

Can you assure your client that provider data has been updated at least monthly – or even more frequently?

Are all providers viewable through the Internet current, valid and usable by plan members?

Can you offer any client a customized provider network even if the group is small?

If your client wants a choice of multiple networks in the same area, how do you choose which network contract to use for each physician?

Are the time and cost of providing competitive provider access and disruption reports proving to be significant?

To answer these complicated questions, begin with a simple phone call.

Contact ProviderKey today and begin your journey toward provider data that gives you a distinct competitive advantage.

1. Are you trapped in an endless cycle of provider data cleanup initiatives?
2. Have you thought strategically about the competitive possibilities that provider data technology offers your organization?

1. Describe your business in terms of product lines such as insured or ASO, etc. What are your most important market locations and how many states do you operate in?
2. What is your mix of business? Are your clients comprised of individual insureds, small group, self-funded or large group insureds? What is the number of covered family units in each business category?
3. How many PPO networks (medical, dental, pharmaceutical, mental health and other networks in this section) are contracted by your organization? How often is data received from each network?
4. Do you contract with any carve-out networks such as mental health or chiropractic? How do you remove the mental health from the medical and organizational contracted networks?
5. Does the network send a general demographic (all providers, all locations) data set or is it customized for your organization’s use?
6. Do you use data cleansing programs to prepare data for your systems? How many people or resources are involved in cleaning and loading the data?
7. What works best in your provider file? What are the greatest needs for improvement? Do you have any current or planned project initiatives for provider file cleanup or system upgrades/updates?
8. Do you have any claim processing improvement initiatives in progress or planned that require an improved use of provider file data? Do you use the data in a preproduction (test) system prior to production rollout?
9. Do you have any “Operational Excellence” initiatives in progress or plans to improve the claim payment accuracy and provider data processing on behalf of your most important provider partners?
10. Do you ever have to customize the provider networks’ coverage to meet the needs of a health plan or large client by defining geographic coverage or included specialties?
11. How do you translate the various provider category and specialty schemes into a customized set of definitions that can be properly used by your information systems, plan members and insureds?
12. Do you use the data for any additional purposes other than paying or repricing claims, such as identifying providers in a claim or offering plan members access to a printed or online directory?
13. If you contract with many different PPO networks, how do you offer plan members consistent web functionality and data sets that apply specifically to your requirements?
14. How do you maintain provider eligibility and apply that to claims? In other words, do you require any manual intervention to maintain all of the historical data sets for each network over time including the effective and termination dates for providers to properly match and validate historical claim records?
15. Do your claims or repricing administrative systems access a web service that uniquely identifies the provider in a claim, adds current demographic information to the record and verifies the provider’s eligibility on the claim date? If so, is this effective, accurate, timely and cost effective?
16. Can you uniquely identify the providers in your claims or repricing system and all of the names, address and tax ID variations?
17. Do you have to supply provider access or disruption reports to prospects in a competitive bidding process? Is this process automated? Is it a valuable resource to prospects, or just another part of the RFP checklist? Should it be something that you use more effectively to distinguish your services from the competition?