Designing a Health Plan’s Internal Provider Data Management Operations

The Challenge

A large, integrated health plan struggled to solicit organizational support for investments in provider data management solutions. They lacked the well-defined roles, processes, and systems needed to manage provider datasets critical to internal operations, yet faced new regulatory requirements that increased the imperative to address these internal challenges. The health plan engaged crankfrog to garner leadership buy-in for the establishment of a new shared service to oversee provider data management functions, determine how to best leverage existing data resources to directly support provider data needs, and support the plan’s near-term gap closure activities.

Our Approach

crankfrog performed a detailed inventory and analysis of new provider directory regulatory requirements published by CMS, NCQA, and state-based entities specific to the markets in which this plan operated. crankfrog assessed current state processes and systems to identify additional gaps in the plan’s ability to meet operational needs and regulatory compliance, and established an intake process to enable compliance with future regulations. To address internal inefficiencies, crankfrog designed a new centralized provider data management function inclusive of structure, roles, processes and systems requirements.

Results

By the end of the engagement, the health plan had established an enterprise-wide, centralized provider data shared service. To support ongoing stability of the new solution, crankfrog created a set of deliverables that included:

  • A repeatable intake and triage framework, including gap assessments and prioritization;
  • Tracking tools to measure and report on progress to stakeholders at various levels of the organization;
  • Documentation of program structure, including program governance, roles and responsibilities;
  • Actionable solutions to close key regulatory gaps;
  • Transition tools to support the health plan’s expanding team engaged to support provider data management functions across the organization.

crankfrog played a critical role in outlining how the health plan could utilize a centralized shared service to mitigate regulatory exposure, which proved to be the catalyst in securing organizational investment from the leadership team. As a direct result of this work, funding was allocated to hire an entirely new team to support enterprise provider data management functions.