Monitoring Intelligence across the Payer Ecosystem
Your Guide to Better Data, Better Efficiencies for Managing Provider Networks
Across most payer organizations, provider network data is gathered and utilized in silos.
So to start, help us learn a little more about you by answering a few questions below.
Did you know?
Workflow inefficiencies and data inaccuracies across departments are likely costing your organization millions of dollars each year.
The Many Roles of Provider Network Data within Your Ecosystem
YOUR ROLE
OTHER PARTICIPANTS
Better Monitoring Intelligence Breaks Down Departmental Silos
The tremendous costs of healthcare fraud, waste, and abuse (FWA) is an evergreen topic for the US healthcare system. Identifying, investigating, and ending fraudulent and abusive schemes within provider networks demand significant resources. The success of these efforts depend on data speed, accuracy, and cross-functional collaboration across your payer ecosystem. Since provider-committed fraud typically manifests as ongoing cycles of false or upcoded claims and kickbacks, speed-to-action protects revenue.
Tasked with ensuring organizational adherence to federal and state regulations across all primary sources and staying audit ready in a shifting regulatory environment. Often asks:
Are we meeting the internal and external standards for oversight and protecting ourselves from penalties and damages?
Do we have the readily available documentation to prove this?
Compliance
Siloed workflows are no longer good enough.
Centralized provider eligibility and monitoring intelligence ensures data insights exist where stakeholders need it most - and empowers efficient communication across teams. At ProviderTrust, we deliver one powerful platform with a flexible API that breaks down silos, improving quality of care for your members, and reducing both medical and administrative spends for your organization.
With more than a decade of experience in exclusion monitoring and license verification, our one platform approach connects vital intelligence to the moments and workflows you need it most.
We monitor your:
Par and Non-Par Providers
Licensed Employees and Physicians
Non-Licensed Employees and Staff
Vendors, Subcontractors, and Physician-Owned Entities
Contingents, Brokers, and Outside Counsel
State Sanction Lists
OIG LEIE Exclusion Lists
State Licensing Boards
Federal and State Enabling Sources
Across all:
Our Differentiators
Exact-Match Results
Our Workflow Designs
What is your role?
We enrich primary source data for always-accurate compliance monitoring intelligence.
We guarantee exact-match results via automation and real, human verifiers.
We serve the entirety of the healthcare ecosystem through population-specific workflow design, including Networks like yours.
Compliance
Credentialing
Provider Operations
Value-Based Networks
Payment Integrity
Special Investigations Unit
Breaking down silos through a shared commitment of provider network integrity – that’s the power of Better Reimagined™.
Our Compliance Intelligence
Let's Do Better Together
Provider eligibility and monitoring data is pulled from disparate sources at both the Federal and State levels.
Provider data updates are made at varying time intervals.
Provider network data is manually managed and prone to human error.
9m+
people / entities monitored ongoing
4,000+
disciplinary action sources
600+
individual state licensing boards
830k+
licenses monitored continuously
Compliance
Credentialing
Special Investigations Unit
Provider Operations
Payment Integrity
Other
How do you currently utilize provider eligibility data?
Compliance
Credentialing
Special Investigations Unit
Operations
Payment Integrity
Other
Who else in your organization currently utilizes provider network data?
Compliance
Credentialing
Special Investigations Unit
Operations
Payment Integrity
Other
Responsible for ensuring continuous provider eligibility, which in turn upholds quality care standards for members. Often asks:
Is this provider who they say they are?
Do they meet network participation standards?
Credentialing
Responsible for managing the data, processes, and operations involved with upholding the integrity of your provider network and directory. Often asks:
How accurate and complete is our database?
Do we have bad or missing data on our par and non-par providers?
Provider Operations
Responsible for managing the efficiency and effectiveness of the Health Plan’s Provider Networks. Often asks:
How can we as a Health Plan ensure our members are being cared for by the right practitioner at the right time?
How can we build stronger Provider networks using data?
Value-Based Networks
Tasked with claims editing, including identifying ineligible claims, and provider payments, protecting the integrity of government LOBs and the organization’s bottom line. Often asks:
Is this provider eligible for payment?
Are ineligible claims causing unnecessary financial waste and workflow stop-gaps within our organization?
Payment Integrity
Tasked with leading and managing fraud, waste, and abuse (FWA) investigations, including tracking down key provider documentation across disparate primary sources. Often asks:
What evidence can corroborate this lead I’m investigating?
Do we have quick access to the vital documentation that supports this evidence?
Special Investigations Unit
Eligibility Monitoring Sources
Sources Confirming Provider Identity
National Plan & Provider Enumeration System (NPPES)
Social Security Administration’s Death Master List (SSA DMF)
Office of Foreign Assets Control (OFAC)
Licenses and Certifications
State medical license and professional boards
NPDB
CLIA
Federal and State Exclusion Sources
OIG-LEIE
SAM.gov
State Medicaid Excluded or Terminated Provider Lists (44 total)
CMS Status and Authority
CMS Ordering & Referring List
Medicare Opt-Out
CMS Preclusion List
FDA Debarment
DEA Sanctions List
Federal and state primary sources update their data within varying timeframes
Duplicated efforts occur when people across teams check the same provider profile data within their own tracking systems
Poor data hygiene means spreadsheets are outdated as soon as they exist
License and eligibility issues fly under the radar for years at a time
Decentralized provider eligibility and monitoring data results in many hands touching the same information, causing inefficiencies and duplicate work
Varying workflows cause numerous back-and-forth interactions due to the needs of audits, oversight, and interdependent processes
Stop-gaps occur once an eligibility issue is finally identified
Manual checks of primary data sources are time-consuming and tedious, often leading to employees chasing paper trails for up-to-date data
