Provider Monitor

The Challenge of Monitoring Providers

Other than contracting no payer has ever tried to 'manage' us -- large regional provider Is there a better way to 'manage' a provider? The ProviderMonitor in the Decision Desktop makes it easy to track and manage individual providers every day. In many cases, provider management comes down to 'other topics' discussed during the annual contract renewal meetings. Why not turn the tables on your network and with a tool that makes it easy to stay on top of provider payment and claims issues every day?

Provider Management in a Box

The Decision Desktop is a turnkey claims process reporting tool. It was designed to support performance information needs for staff across a payer organization - from provider representatives to CFOs, from claims supervisors to account managers. Payers use the Decision Desktop today to achieve the following:

• Track Provider Payment Issues. Managing providers is perhaps the most significant claims challenge payers face. The common payer/provider dynamic is for the claims process issues to be 'payer driven'. Some claims issues are payer driven. Few payers however, have the tools to manage individual providers for key provider driven metrics such as EDI rate, eligibility denial rate, and eligibility denial rate. The Decision Desktop makes it possible to manage providers in a way they've never been managed.
• Set Provider Administrative Goals. How many of your providers have a duplicate rate less than 5%? How many have an EDI rate over 90%? With the ProviderMonitor you can turn provider relations into provider management. Instead of reacting to provider demands and administrative issues -- frame claims performance targets using the ProviderMonitor and track them. There is no reason you should not expect from your providers the same administrative accountability they expect from you -- the ProviderMonitor makes it prossible.
• Manange Provider Payment Risk. How much was paid, denied and adjusted for the largest provider in your network last week? How about out of network? How does that compare with the week before? The payment alerts in the Decision Desktop allow payers to track weekly payment trends -- and find issues usually before the providers themselves find them.

Innovation, Flexibility, and Scalabilty

How does the Provider Monitor work? It works by combining four core data technologies. First it loads open and closed claims data each day and applies a set of business rules to each claim. This enables the Decision Desktop to uniformly and transparently report performance (Would you like to see the rule used to determine duplicate claim lines?). Second, it aggregates the claim data to enable reporting across periods. Decision Desktop aggregations make it possible to see monthly, quarterly, and yearly views of data for individual providers in seconds (Would you like to see the total volume of claims denied in 2006 as a duplicate for that provider?). Third, it loads the individual claim data into a search engine (claimfetch) that enables users to search on indivual and sets of claims (Would you like to see 100 random claims that were denied as duplicates for that provider?). Fourth, the alert engine enables users to set alerts that track and email individual performance changes (EDI rate drops from 85% to 60%) to users when requested. These four technologies enable robost reporting, alerting, and root cause analysis.