In this blog, I look at how Sutherland tackled the challenge of health plans maintaining accurate provider data in the state of California.

The challenge: inaccurate health plan data about providers

It’s been difficult for health plans in California to maintain accurate, up-to-date information on the current status of providers in the state. According to outsourcing vendor Sutherland, experience indicates that 60% of provider directories contain serious material errors. Health plan data frequently indicated that doctors were no longer accepting new patients, even though they in fact were. The data frequently presented the state regulatory body, health plans, and patients with inaccurate information about whether doctors continued to practice their specialty, had moved to new locations, or were contracted to work with particular health plans or their products.

The context: gaining access to timely CA medical services

Since 2017, Sutherland has created a shared services model for over a dozen CA health plans that obviates the need for participating California health plans to each separately build and update parallel databases that track the availability of provider appointments for urgent and non-urgent care for health plan members. The State Department of Managed Healthcare (DMHC), which regulates the state’s health plans, requires that health plans and providers make available appointments for urgent and non-urgent care, varying by specialty, from two to 14 days. Until recently, each health plan created and updated its own massive database of providers that participated in each of those plan’s products.

In a state in which Sutherland reports that the average provider contracts with ~ 15 health plan products, the law resulted in a myriad of duplicative efforts, each of which imposed burdensome requirements on providers.

The Sutherland solution

Sutherland has initiated a shared services platform that reduces this burden for health plans, providers, and state agencies, and increases the accuracy of reporting to the DMHC. In particular, Sutherland spearheaded the coopetition of health plans in California in 2017 by creating a shared services model that built and updated the Provider Appointment Availability Survey (PAAS) on behalf of a consortium.

Prior to that, Sutherland had been in conversations with the state of California on a related topic, and that conversation helped initiate Sutherland’s PAAS project with the state. Sutherland had already built a relationship with Blue Shield of CA, which became the anchor client. Other state-based and national health plans joined the consortium in 2017, totaling eight by the end of 2017. By the end of 2018, 12 health plans had joined the consortium and Sutherland now counts that consortium at 14 health plans.

Sutherland estimates that it now touches ~ 100K doctors, each of which has contracts with an average of two plans. This hub-and-spoke shared services model eliminates duplicate outreach to CA providers, saving each participating health plan from the costs of maintaining separate call center facilities and databases, and saving providers from responding to multiplicative health plan outreach regarding the same basic data. Sutherland also manages all the workflows involved with credentialing a new provider, verifying diplomas, board certifications, and combing regulatory authorities for any information on sanctions against providers.

The company estimates that it reduced associated health plan physician data management costs by 75% through elimination of duplicative work and by improvement in survey execution workflow and other improvements. Sutherland estimates that it reduces the touches on providers from 3 to 1 call per practice, improves reporting and other interactions with the California regulatory body, and improves patient access to timely care.