Health Net: Improving the Primary Source Verification Process

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EXECUTIVE SUMMARY

Costly data acquisition fees, human data entry errors, manual processes, incomplete files and provider abrasion are a few reasons why Health Net explored opportunities to improve their credentialing and primary source verification process.


The credentialing department was considering the services of other credentials verification organizations (CVO) to manage the increased file volume. However, Health Net had concerns around their timeliness, data integrity, lack of responsiveness and unknown costs, and as a result the department decided to go in a different direction.


The health plan’s existing experience with other CAQH provider data solutions had been a positive one. They decided to work with the VeriFide team to address their need to handle the larger PSV file volume while increasing quality and speed.

THE CHALLENGE

As a result of its acquisition by Centene, Health Net needed to adopt their credentialing policies; this included an increase in the types of healthcare providers requiring credentialing. The scope of the Health Net provider network had increased in size by 27 percent and the adopted-time metrics for onboarding providers were reduced. Given the volume and the size of its staff, this was not achievable without additional assistance or resources.

THE SOLUTION

After implementing VeriFide the credentialing team has increased its file volume by one-third and improved overall quality by 5 percent. Without utilizing the resources of VeriFide to meet the new demand, Health Net estimated it would need to hire between six and eight associates to manage the volume internally.

THE RESULTS
Reduction in labor costs
20%
Decrease in the number of days required to complete PSV activities
12-Day
Improvement in overall data quality
5%
Increase in file volume
1/3rd

Improved operational efficiencies

Credentialing, re-credentialing and PSV file accessioning has reached the projected level of 4,800, with the ability to scale accordingly.

Improved PSV completion times through automating manual processes

Through automating the extraction of CAQH ProView data, as well as national and state monitoring and licensing data, the team has experienced a 12-day reduction in the amount of time required to complete PSV activities.

Reduced data entry errors

The data supplied by VeriFide is easy to read and interpret, reducing the potential for errors. Health Net is upgrading its automation technology, and as a result, VeriFide files are now delivered in two formats — machine and human-readable.

Ensure the imported elements met regulatory requirements, and reduced audit vulnerability

Imported data elements were aligned with NCQA, Federal and state requirements. The Health Net 35-element manual data verification process was replaced with an automated, NCQA-compliant checklist.

Proper staff and resource allocation

The Health Net team used the rules-based categorization of PSV results to route files to different work queues based on outcomes. The credentialing team re-deployed its staff associates to address files with codes indicating “irregular results,” and “data element confirmed deficient after provider outreach.” Health Net has netted a ~20% reduction in labor costs, and eliminated the need to hire
additional staff.

Eliminated pass-through fees

The flat-rate pricing in VeriFide combines data extraction fees for monitoring and licensing databases, and for CAQH ProView data. 

Learn more about VeriFide. 

Without utilizing the resources of VeriFide to meet the new demand, Health Net estimated it would need to hire between six and eight associates to manage the volume internally.