The healthcare system has undergone remarkable innovations and technological advances – the digital age brought us telemedicine, AI-driven diagnostics, and personalized treatments supporting whole-person health, to name a few.
Yet, despite these breakthroughs, we are fundamentally building on top of an archaic system. The legacy of manually processed administrative burdens holds us back – it consumes time and resources, preventing every healthcare advance from reaching its full potential.
How can we expect providers to leverage innovations and new technologies when they are still required to spend hours every day completing physical paperwork that must be mailed or faxed? How many patients are unable to find a specialist in their network because the provider directory is severely outdated? How many providers are delayed in receiving payment for their services because payers do not have the correct file information? And for how long do doctors sit on the sidelines, unable to see patients, because their licenses have not been verified?
Integrated Enrollment Platforms and Consumer Assistance Centers: The Strongest Advantage for State-Based Exchanges
In the ever-evolving landscape of state-based health insurance exchanges, the convergence of technology and customer service is reshaping how these exchanges operate. The increasing advent of automation and artificial intelligence (AI) is rapidly dismantling the traditional business model that relies on the siloing of technology and customer service centers.
The answers to these questions are startling.
A 2021 study found that providers spend 20% of their time managing network participation at the expense of patient care. According to research by McKinsey, most health systems are still bogged down by slow, labor-intensive processes—like verifying provider credentials manually or relying on outdated digital methods like data scraping. Even at the height of the pandemic, over 70% of healthcare providers still exchange information by fax. Manual administrative tasks make up the largest category (about 30%) of wasteful healthcare spending, equating to up to $280 billion in annual avoidable costs.
While provider applications are pending with health plans or hospitals, a provider cannot see new patients or administer care. That can mean months of lost opportunities to administer life-changing treatments and generate essential revenue. Even worse, if a provider is credentialed irresponsibly with outdated, inaccurate, or incomplete data the very patients we seek to serve can ultimately be harmed. Manual credentialing processes can take up to 180 days, while medical licensing can take up to 60 days after an application is submitted, opening the door for outdated and inaccurate data by the very nature of time passed.
According to the Council for Affordable Quality Healthcare (CAQH), the cost of plan directory provider maintenance totals $2.76 billion annually; yet, according to the American Medical Association (AMA), 33% of directory listings are inaccurate, including nonworking phone numbers, incorrect addresses, and just plain wrong practice areas.
How AI and Machine Learning Can Transform Pharmacy Benefits Management
Abarca executives see plenty of potential for new technologies but note the need to strike the right balance between tech and human intervention.
These administrative inefficiencies create a bottleneck that hinders the entire healthcare system. One recent analysis suggests that these kinds of time-consuming processes were to blame for how unprepared the U.S. health system was (and still is) to respond to the crisis of the Covid-19 pandemic.
Administrative burdens also contribute to provider burnout, patient frustration, and financial strain on healthcare institutions. One study estimates that inefficient, repetitive workflows in provider data management collectively cost the U.S. healthcare industry over $2.1 billion annually, with health insurers taking the biggest hit.
Without addressing this underlying antiquated incumbent issue, our healthcare system will remain held back, unable to fully benefit from the innovations designed to improve patient outcomes and operational efficiency.
Technologies like artificial intelligence and machine learning will play a crucial role in creating a more efficient and transparent system. To move forward, health plans and hospital systems must prioritize the modernization of administrative processes. This means adopting digital solutions that streamline provider credentialing, improve the accuracy of provider directories, and automate payment processes.
Research has shown that there are twice as many administrative staff as there are clinicians working in U.S. healthcare. There are over 22 million healthcare providers in the United States. A single source of truth in provider data management will unlock a tremendous amount of their employers’ resources and their individual time that is currently wasted on administrative burdens.
Most importantly, by freeing providers from administrative burdens, we can open up their time to focus on what truly matters: patient care.
Photo: Nuthawut Somsuk, Getty Images
Anshul Rathi is the Founder and CEO of CertifyOS, a first-of-it’s-kind provider intelligence platform that delivers frictionless licensing and enrollment, one-click credentialing, and real-time network monitoring. Prior to CertifyOS, Anshul was at Oscar Health where he built the credentialing operations division from the ground up, rightfully earning the “one-man credentialing army” moniker. The development of the division was key to ensuring compliance and supporting the company as it scaled to new markets. While at Oscar he helped reduce the time it took to contract new doctors in both new and existing markets by 50%. He earned his Bachelor of Engineering at Nagpur University in India, and his Masters of Science at Brown University. He travels frequently between the United States and India.
This post appears through the MedCity Influencers program. Anyone can publish their perspective on business and innovation in healthcare on MedCity News through MedCity Influencers. Click here to find out how.
