Latest / Becker’s Payer Issues Podcast / Navigating Network Compliance in Healthcare: Trends, Challenges, and Digital Transformation Insights

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Navigating Network Compliance in Healthcare: Trends, Challenges, and Digital Transformation Insights · Becker’s Payer Issues Podcast

• 0:00
  Hello, everyone. This is Jacob Emerson with Becker's
• 0:02
  Health Care. Thanks so much for tuning in
• 0:04
  to the Becker's Health Care podcast, where today
• 0:06
  we're gonna be talking about navigating network compliance
• 0:10
  and the top trends, value, and outcomes.
• 0:12
  So joining me for today's discussion is Gianni
• 0:15
  Aiello, who is the vice president of product
• 0:17
  at Verifiable. Gianni, thanks so much for taking
• 0:20
  the time to be with me on the
• 0:21
  podcast today.
• 0:22
  Yeah. Thank you, Jake. Absolute pleasure to be
• 0:24
  here. Excited for the conversation today.
• 0:27
  Likewise, Gianni. And before we dive into that,
• 0:29
  can you tell us a little bit more
• 0:30
  about yourself in terms of the the work
• 0:33
  you do at Verifiable
• 0:34
  and the role that the company plays within
• 0:36
  our health care system?
• 0:38
  Yeah. Sure. So, for the audience here, my
• 0:40
  my name is Jenny Hagan. I'm VP of
• 0:42
  ProductVerifiable,
• 0:43
  and I've been at the company now just
• 0:45
  over 18 months.
• 0:46
  But over the past 15 years, I've been
• 0:48
  a product leader at various different technology companies,
• 0:51
  including identity security and AI based voice to
• 0:54
  text solutions,
• 0:56
  both of which that served health care customers.
• 0:58
  So have a pretty extensive background in in
• 1:01
  serving health care organizations.
• 1:03
  At Verifiable,
• 1:04
  my role sort of centers around advanced our
• 1:06
  mission
• 1:07
  to become the autonomous system of record verified
• 1:09
  provider credentials.
• 1:11
  We really wanna streamline
• 1:13
  the often as as I think most people
• 1:14
  can understand the complex and
• 1:16
  sometimes resource intensive process in health care around
• 1:19
  credentialing,
• 1:20
  and we really want to divert those that
• 1:23
  that resource back to patient care. So we're
• 1:24
  that's sort of our primary mission.
• 1:27
  I'll sort of end with, like, we we
• 1:28
  believe that partitioning facility credentialing and monitoring shouldn't
• 1:30
  take weeks or months.
• 1:32
  It can be done in hours or even
• 1:33
  minutes.
• 1:34
  And, I think achieving that is is going
• 1:36
  to be about embracing technology, but also rethinking
• 1:39
  the way about the way way in which
• 1:40
  we go about doing some work. So, yeah,
• 1:42
  that's a little bit about me and and
• 1:44
  our mission at Verifiable.
• 1:45
  Fantastic. Well, appreciate you filling us in there,
• 1:47
  Gianni. And as you know, compliance is crucial
• 1:51
  in maintaining
• 1:52
  trust with patients and organizational
• 1:55
  integrity.
• 1:56
  So to get us started, can you explain
• 1:57
  the core components of a successful network compliance
• 2:00
  program
• 2:01
  and the trends that you're seeing today across
• 2:03
  the landscape?
• 2:05
  Yeah. So there's sort of a varied perspective
• 2:08
  in the market
• 2:09
  around, like, what does what is needed for
• 2:11
  compliance. There's a lot of different elements to
• 2:14
  it. I'm I I obviously, given our focus
• 2:16
  is very credentialing centric,
• 2:18
  I'll I'll lean that way, but there are
• 2:20
  things that are very adjacent
• 2:22
  to compliance around things like network adequacy
• 2:25
  as an example,
• 2:26
  and, this the timing delivery of claims reimbursement
• 2:29
  that are that are part of a a
• 2:31
  compliance
• 2:32
  solution as well.
• 2:33
  But I'm gonna talk about sort of the
• 2:35
  the high level fundamentals that I think that
• 2:37
  make, a good compliance program irrespective of, like,
• 2:40
  the core mission of or the the use
• 2:42
  case that you might be solving within the
• 2:44
  scope of compliance.
• 2:45
  So I would say that the first step
• 2:47
  is really about data sharing and onboarding.
• 2:49
  There's always a step around how data is
• 2:51
  being shared between
• 2:53
  a provider organization and a payer organization,
• 2:55
  and that's often an area of friction.
• 2:57
  Rosters are a good example of, like, a
• 2:59
  data point or a a a format
• 3:01
  of data that's exchanged between organizations,
• 3:04
  and and having that exchange be as frictionless
• 3:07
  as possible is gonna be critical.
• 3:10
  The second step is, unsurprisingly, process automation.
• 3:13
  There is a lot of still manual activity
• 3:15
  that goes on in the process
• 3:17
  to exchange information,
• 3:19
  to validate and verify information,
• 3:21
  and then ultimately make decisions on that information.
• 3:25
  And so we believe that, you know, there
• 3:27
  there are some really compelling ways to to
• 3:29
  really better manage that that process,
• 3:32
  and and we think that customers need to
• 3:33
  sorry. Organizations need to drive towards that.
• 3:36
  And the first step is, like, an efficient
• 3:38
  and streamlined this is more specific to our
• 3:40
  world, like, credentialing process.
• 3:41
  We really do think that's sort of a
• 3:43
  starting point in the journey around compliance,
• 3:45
  around practitioners and facilities.
• 3:48
  Without having a credentialed facility or practitioner, you
• 3:50
  can't really get onto the other sections
• 3:53
  of compliance. And so having good packet creation,
• 3:56
  a focus committee review that focuses on risky
• 3:58
  cases versus
• 3:59
  everything that's coming through the organization
• 4:02
  is very important.
• 4:04
  And 2 more steps. The 4th step would
• 4:06
  be just provide them facility risk management. Like,
• 4:09
  okay. You've done credentialing,
• 4:11
  but that isn't where it ends. Right? A
• 4:13
  compliance program is an ongoing
• 4:15
  it's a program for a reason. It it
• 4:17
  needs ongoing monitoring. It needs ongoing management.
• 4:20
  So how do we make it so that
• 4:21
  as things change,
• 4:23
  practitioners change, facilities change,
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  how are those risks being serviced in a
• 4:27
  way
• 4:28
  that makes the distribution
• 4:30
  much more straightforward and
• 4:32
  ultimately reduces down any potential liability concerns that
• 4:36
  might come from an issue that arises.
• 4:39
  And then last and certainly not least is
• 4:40
  just then then there is a a a
• 4:42
  network effect. Once this data is there, once
• 4:45
  it's available,
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  how it can be distributed into other parts
• 4:48
  of the process, and sometimes it's not even
• 4:50
  compliance related processes, honestly.
• 4:52
  It could be something like just
• 4:54
  when do you unlock a specific provider
• 4:58
  from being available to for for claims reimbursement
• 5:00
  as part of an insurance plan. Like,
• 5:03
  the compliance program should be the arbor of
• 5:05
  that decision,
• 5:06
  and making sure that the system is interchangeable
• 5:08
  and quick to to allow that downstream system
• 5:10
  to to consume that context
• 5:12
  is really critical. So that's sort of the
• 5:14
  5 steps that we see, that are really
• 5:16
  important to a successful compliance program.
• 5:19
  Understood. And I appreciate you sharing those 5
• 5:22
  steps with us, Gianni. To follow-up with you,
• 5:24
  based on your experience and based off what
• 5:26
  verifiable
• 5:27
  is seen, ultimately, what's keeping payer organizations
• 5:30
  from effective network compliance?
• 5:33
  What are some of the barriers that that
• 5:35
  they're facing?
• 5:36
  Yeah. So I think there are there's gonna
• 5:38
  be a bit of a theme in some
• 5:39
  of my, like, my my thoughts here, I
• 5:41
  think. I think there's, like, an organizational
• 5:44
  reality, like, a business relationship
• 5:46
  thing or barrier, and then there's a technology
• 5:48
  barrier, and I'll talk about them both a
• 5:50
  little differently.
• 5:51
  So when it comes to the sort of
• 5:53
  the organizational barrier, you know, we are finding
• 5:56
  that there is a lack of efficient data
• 5:58
  sharing and collaboration
• 5:59
  between providers and payers in the industry.
• 6:02
  The relationship between these stakeholders often feels siloed
• 6:05
  with significant walls
• 6:07
  that need to be broken down, honestly. Like,
• 6:09
  it's it's a real problem.
• 6:11
  And without that partnership and streamlined process, compliance
• 6:14
  becomes
• 6:15
  really burdensome for everyone involved.
• 6:17
  Like, a major issue is the absence of
• 6:19
  an agreed upon standard for data exchange. Providers
• 6:22
  are often required to navigate,
• 6:24
  like, unique payer specific requirements for sharing information.
• 6:28
  Those requirements vary not because of, like, any
• 6:30
  meaningful difference in policy,
• 6:32
  but due to each payer's interpretation of those,
• 6:35
  those tasks and rules.
• 6:37
  So these differences aren't helping sort of anyone
• 6:40
  from an insurance perspective, like, drive differentiation. This
• 6:43
  is not like a a reason why organizations
• 6:46
  are differentiating.
• 6:47
  And so we really do need to break
• 6:49
  down that barrier
• 6:50
  because, you know, we do see we speak
• 6:51
  with we we fortunately serve both sides,
• 6:54
  and providers are having to deal with, like,
• 6:56
  15 different roster templates for different insurance companies.
• 6:59
  And they're having to provide different information, which
• 7:02
  means that data can sometimes get out of
• 7:04
  sync and and or different. And then on
• 7:06
  the on the insurance side, that means they
• 7:08
  also have to understand that the product the
• 7:10
  provider might be presenting information in incomplete formats.
• 7:14
  So that's one area. It's not really about
• 7:16
  technology. It's about, like, agreeing upon a set
• 7:18
  of principles, and I know that this is
• 7:20
  probably not this has been talked about for
• 7:21
  years.
• 7:22
  But and, honestly, until this gets resolved, this
• 7:25
  is gonna continue to be a real big
• 7:26
  challenge for a lot of organizations.
• 7:29
  We need some collective,
• 7:31
  decision making to to really break down that
• 7:33
  wall. I did wanna pull out that, like,
• 7:35
  we do also see that there is a
• 7:37
  real need on the technology side to just
• 7:40
  embrace more digitization. Like, I'm not we can
• 7:42
  we'll talk I'm sure we'll talk about that
• 7:44
  in in as we continue here. But, obviously,
• 7:47
  the more you can leverage Ditto assets and
• 7:50
  you can leverage more,
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  electronic communications is going to drive much more
• 7:54
  efficiency here. And that's not just a statement
• 7:56
  of insurance and provider organizations. That's also the
• 7:59
  government and others that are the arborists of
• 8:01
  this information. And so we have to modernize
• 8:03
  in a lot of areas the technology stacks
• 8:05
  so we can become more efficient.
• 8:08
  Absolutely. And let me let me go back
• 8:09
  to your first point there, Gianni, about data
• 8:11
  privacy
• 8:12
  because we're we're constantly seeing the health care
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  industry, both payers and providers, have to constantly
• 8:17
  deal with evolving laws and and regulations in
• 8:21
  this space.
• 8:22
  So how would you say that payers should
• 8:24
  be evolving their compliance programs with those evolving
• 8:27
  regulations?
• 8:29
  And then to follow-up with your second point,
• 8:30
  what's the role that digital transformation
• 8:33
  can play in that?
• 8:36
  Yeah. You know, evolving data proxy laws
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  and regulations, I've I've I've been in another
• 8:41
  set sector, which is more about identity regulations.
• 8:43
  And so it's always an ever changing,
• 8:46
  benchmark. Right?
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  But I think when it comes to digital
• 8:49
  transformation and compliance programs, you know, a digital
• 8:52
  footprint allows organizations
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  to easily track where data resides and how
• 8:57
  it's stored and who is who has access
• 8:59
  to it.
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  This level of visibility is almost impossible to
• 9:03
  achieve in a lot of the manual physical
• 9:05
  data management processes that sometimes still exist today,
• 9:08
  in particular where there's exchange between different services
• 9:11
  organizations around credentialing and managing these processes.
• 9:14
  So, like, with the right technologies, payers can
• 9:17
  control access,
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  enforce robust security measures, and and most importantly,
• 9:21
  maintain sort of a detailed audit trail to
• 9:23
  track who is who is accessing or modifying
• 9:27
  this sensitive private data, right, which is ultimately
• 9:30
  where where the regulations are all moving.
• 9:32
  This transparency is not only helps in mitigating
• 9:34
  risk, but also ensures compliance and evolving regulatory
• 9:37
  framework. So if you have this benchmark and
• 9:39
  this foundation,
• 9:40
  it becomes much more straightforward for you to
• 9:42
  adjust as as the benchmarks change.
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  You know, at Verifiable, we take this step
• 9:48
  further by providing sort of a deep audit
• 9:50
  trail across our platform.
• 9:52
  These trails sort of track every instance of
• 9:54
  data manipulation or access who have made the
• 9:56
  change,
• 9:57
  what was altered and when it occurred, And
• 10:00
  that sort of is the information that you
• 10:02
  need to be able to present in reports
• 10:04
  to anybody that is gonna be reviewing your
• 10:06
  privacy,
• 10:08
  regulations or or policies internally to make sure
• 10:10
  that you're you're keeping in line with those
• 10:12
  things and you don't expose yourself to additional
• 10:14
  risk.
• 10:15
  We also align with various accreditation bodies like
• 10:18
  NCQA
• 10:19
  around their expectations around handling,
• 10:22
  as well as joint commission and others to
• 10:24
  make sure that we're sort of meeting their
• 10:26
  minimum bar as well around the tracking of
• 10:28
  information as well.
• 10:30
  So, Johnny, let's talk about the ROI piece
• 10:32
  of all this. Obviously, it's it's important to
• 10:35
  create buy in on on new digital transformation
• 10:38
  projects.
• 10:39
  Can you share some examples for us in
• 10:41
  terms of short term and long term KPIs
• 10:44
  that you and Verifiable consider critical for a
• 10:47
  successful network compliance program.
• 10:50
  Ultimately, how can the leaders listening in right
• 10:53
  now measure their success in this space?
• 10:56
  Yeah. Obviously, we we we deal with a
• 10:58
  lot of different customers
• 11:00
  and organizations with actually varying different needs.
• 11:03
  But there are some sort of consistent perspectives
• 11:06
  here that we we do see irrespective of
• 11:07
  use case. And so in the short term,
• 11:10
  I think the most immediate ROI does tend
• 11:12
  to came come from an I don't think
• 11:14
  it's a surprise sort of efficiency gains internally.
• 11:17
  For example, our platform is incredibly efficient at
• 11:19
  performing primary source verifications and completing them in
• 11:22
  seconds.
• 11:23
  That translates to significant time and cost savings
• 11:26
  for internal teams
• 11:27
  that allows to freeze them from a lot
• 11:29
  of the repetitive tasks that they have to
• 11:31
  do there. It also improves the organization's risk
• 11:34
  posture because many customers were, you know, conducting
• 11:37
  as many as
• 11:38
  weren't even conducting certain verifications on Like, they
• 11:41
  were just didn't have the capacity to do
• 11:43
  it. So that leaves them exposed,
• 11:46
  when it comes down to,
• 11:48
  how they measure. Risk is always a more
• 11:50
  challenging ROI to measure. It tends to be
• 11:52
  like, what is the potential liability risk, which
• 11:54
  honestly, based on some of the cases that
• 11:56
  are out there, we're talking 1,000,000 and 1,000,000
• 11:57
  of dollars of potential
• 11:59
  liability risk. But there is real tangible efficiency
• 12:02
  gains that you can build an ROI model
• 12:04
  around in just internally
• 12:06
  around your team and how much more efficient
• 12:08
  you can be with certain digital transformation automation
• 12:11
  being put in place.
• 12:13
  In the long term,
• 12:14
  I think ROI is often seen
• 12:17
  in in sort of the speed and fluidity
• 12:19
  fluidity of data availability across the organization.
• 12:22
  So one of the inherent challenges is when
• 12:24
  you have sort of a bunch of disparate
• 12:26
  silos of data, you become much more inefficient
• 12:29
  in being able to
• 12:31
  flow through different scenarios and use cases,
• 12:34
  across the organization, and that creates sort of
• 12:36
  a rip ripple effect.
• 12:38
  We do see that these improvements lead to
• 12:40
  better you know, if if you solve the
• 12:43
  fluidity of data and how it can also
• 12:45
  be exchanged, so if you have a centralized
• 12:46
  data store where data is being shared across
• 12:49
  the organization
• 12:50
  and and it's and it's accurate,
• 12:52
  it leads to better member sentiment and stronger
• 12:55
  network adequacy, which you can measure. So you
• 12:57
  can actually tie
• 12:58
  member sentiment around things like your provider directory
• 13:02
  or the outcomes that you're driving from network
• 13:05
  adequacy
• 13:07
  to the
• 13:08
  improved efficiency of the collection of provider and
• 13:10
  facility information in a centralized store. And so
• 13:13
  we think that's another interest in our AI
• 13:14
  model that's a little bit more centered around
• 13:17
  the the member
• 13:18
  that is a more of a longer term
• 13:20
  play that once you get to a solid
• 13:21
  base, you can start to showcase the the
• 13:23
  tangible impact you're having there. So I think
• 13:26
  those are the sort of the primary areas
• 13:27
  I'd say. Efficiency gauge is obviously risk posture
• 13:29
  are the 2 short term. Speed and fluidity
• 13:32
  of data and and drive it towards member
• 13:33
  sentiment and network adequacy would be the more
• 13:35
  longer term place.
• 13:37
  Understood. And clearly still a lot of ongoing
• 13:39
  challenges in terms of network compliance success.
• 13:43
  But in that vein, Gianni, if you were
• 13:45
  looking ahead into your crystal balls as we
• 13:47
  enter a new year,
• 13:49
  what's one thing that you want health care
• 13:50
  leaders to be prepared for? And can you
• 13:53
  share some of the best practices that you've
• 13:55
  observed in your work with health care organizations
• 13:58
  all over the country?
• 14:00
  Yeah. I'm gonna I'm gonna probably, talk about
• 14:03
  2 things versus 1,
• 14:04
  cheat a little bit, because I do think
• 14:06
  that they're sort of I I've sort of
• 14:07
  touched it a little bit throughout,
• 14:09
  to to answer some of the other questions,
• 14:11
  but I think there are sort of 2
• 14:12
  areas to think about, honestly. 1 is sort
• 14:14
  of, like, leadership and organizational approach and some
• 14:17
  of the things that we observe with partners
• 14:19
  and organizations that we're working with and and
• 14:21
  and seeing success with. And then there's sort
• 14:24
  of the technology
• 14:25
  lens that I'm sure is sort of given
• 14:27
  my role and and what I represent would
• 14:30
  be what people would expect me to answer
• 14:31
  on. So I'll start with the leadership and
• 14:33
  then land on the technology. So
• 14:35
  I I think leaders who are achieving meaningful
• 14:37
  wins are those who sort of embrace the
• 14:39
  reality of digital transformation
• 14:41
  as an iterative journey
• 14:43
  rather than a one and done overhaul.
• 14:45
  We find that success
• 14:47
  the the most successful companies are focusing on
• 14:49
  incremental improvements in specific areas and coming back
• 14:52
  to sort of my 5 steps. Right? We
• 14:54
  have a number of customers that are, like,
• 14:56
  very focused on, for example, either the credentialing
• 14:59
  packet creation
• 15:01
  or the risk posture management on the compliance
• 15:03
  side, so the monitoring portion of it. And
• 15:05
  they they're they're very focused on that and
• 15:07
  getting that into a better place,
• 15:10
  as step 1, and and showing results
• 15:13
  as an example.
• 15:14
  And so
• 15:15
  I mean, that's a really,
• 15:17
  a critical thing, and we've seen that there
• 15:18
  are customers that are in contrast to the
• 15:21
  embark on on a more monolithic project approach,
• 15:24
  where they're attempting to completely reimagine the process
• 15:27
  in one go
• 15:28
  and often face significant changes or they tend
• 15:32
  to fail, honestly, to meet their goals. We've
• 15:34
  seen the approach work firsthand with 1 customer
• 15:37
  that I I unfortunately, I can't I can't
• 15:39
  state, but they're a very well known,
• 15:41
  insurance company, and they sort of become a
• 15:43
  beacon for this iterative methodology, and the result
• 15:46
  speaks to themselves. I think they've seen massive
• 15:48
  improvements in team morale
• 15:49
  across their compliance credentialing teams.
• 15:52
  They've seen measurable improvements in their key performance
• 15:55
  indicators and their focus areas, and they've ultimately
• 15:58
  seen,
• 15:59
  operational success as well. They've been able to
• 16:01
  achieve quicker time to value, and and they
• 16:03
  were able to realize their ROI model that
• 16:06
  presented the budget to go and do what
• 16:07
  they did. So and they did it through
• 16:09
  not trying to do everything, and and I
• 16:11
  think that's a really important thing
• 16:13
  that surprisingly still isn't always embraced, which is
• 16:16
  why I bring it up. Like, the amount
• 16:18
  of times we deal with customers that are
• 16:19
  trying to just reinvent the entire process
• 16:22
  from scratch, and FAO is sort of it's
• 16:25
  surprising that it still occurs.
• 16:27
  On the technology side, I think well, honestly,
• 16:30
  I'm not someone that I'm not the type
• 16:31
  of product leader that gets excited about technology
• 16:34
  for for for its own sake.
• 16:36
  I do think it's impossible to ignore the
• 16:38
  impact of automation and AI
• 16:40
  and what it will have in how you
• 16:41
  go about doing network compliance.
• 16:44
  In particular around credentialing, it it will change,
• 16:48
  how work is done. And I think leaders
• 16:50
  who embrace these tools are better positioned to
• 16:52
  drive meaningful results.
• 16:54
  And a network compliance involves many manual and
• 16:56
  time consuming tasks that don't really add a
• 16:58
  ton of, like, man like, don't require a
• 17:02
  lot of, like, critical understanding of things. I
• 17:04
  I, you know, for example, I I can
• 17:06
  perform these tasks not only more cost effectively,
• 17:08
  but often with higher accuracy than traditional approaches.
• 17:12
  And and we're seeing that, like, you know,
• 17:13
  at Verifiable, we're particularly excited about the potential
• 17:16
  of AI to address 2 sort of critical
• 17:17
  areas. 1 is in the data onboarding process
• 17:21
  where I can help highlight required data based
• 17:23
  on provider types. So whether it's an MD
• 17:26
  that's being credentialed in MP or RN, we
• 17:27
  can do a much better job leveraging AI
• 17:29
  and to and calling out gaps or areas
• 17:31
  that we think need to be adjusted
• 17:33
  based on our understanding of the datasets that
• 17:35
  are out there and being more proactive.
• 17:37
  And that's something that's just
• 17:39
  not meaningfully
• 17:41
  valuable in comparison to a production specialist that
• 17:43
  needs to evaluate the entirety of the information
• 17:46
  and make critical decisions around how information is
• 17:48
  presented to the committee.
• 17:50
  Another example would be, like,
• 17:52
  AI holds promise in in the reviewing of
• 17:54
  adverse actions,
• 17:56
  that are associated to,
• 17:58
  a credentialing process. So when there is a
• 18:00
  discrimination or something that occurs during
• 18:03
  normal business work hours, how does AI generate
• 18:05
  summaries and highlight key points so that the
• 18:08
  committee can be more efficient and the decision
• 18:10
  makers
• 18:11
  are more effective in that decision making versus
• 18:13
  having to go through a lot of additional
• 18:16
  details around things that sometimes is not necessary
• 18:18
  to the through the context of the decision
• 18:20
  being made. So I think they're the 2
• 18:22
  sort of big areas that I'm really excited
• 18:24
  about and areas that I'm I I hope
• 18:26
  leaders embrace because I think that's gonna lead
• 18:28
  to to the best results for them over
• 18:30
  the next, couple of years.
• 18:32
  Wonderful. Well, it's a lot of great advice
• 18:34
  and I think a great place to leave
• 18:36
  things. So, Gianni, thank you so much for
• 18:38
  taking the time to sit down with us
• 18:40
  and for sharing your insights with our listeners.
• 18:42
  We truly appreciate
• 18:44
  it. Yes. Thank you, Jacob. Pleasure.
• 18:46
  I'd also like to thank Verifiable for sponsoring
• 18:48
  today's episode. You can tune in to more
• 18:50
  podcasts from Becker's Healthcare by visiting our podcast
• 18:53
  page at beckershospitalreview.com.