When providers transition amongst coverage networks, the results can be unexpected out-of-network bills to patients and an administrative burden on healthcare businesses managing coverage. Representing an important step forward in the trend towards increased transparency in healthcare, today, Vericred, based in New York City, is releasing a new offering in the form of provider-network notifications. Vericred, a healthcare data services company begun in 2014, made the announcement at this year’s AHIP Institute and EXPO event in New York City. The new capability provides value throughout “the lifecycle of a member’s enrollment in a health plan.” When members are looking for coverage, the service can help identify which providers are in-network or help a member find a plan for which their preferred provider is already in-network. Once on a plan, notifications can alert members if their provider leaves the network and help find a new one before the next time they need medical assistance.

Members are not the only ones who may benefit from the new service. HR and benefits administration systems, private and public exchanges, health and wellness apps, and health insurance carriers are just some examples of  insurtech companies and services that may benefit from Vericred’s new service. Any organization using the service can register patients or members and tie those individuals to a list of providers. Anytime there is a change in Vericred’s provider-network data, alerts are sent to the organization, which can then take action such as sending a push notification or other alerts to individuals affected by the change.

“Patients, providers and plans all benefit from proactive provider-network alerts. Creating a smart notification service is another step in our overarching mission to drive innovation in healthcare through data,” said Michael W. Levin, CEO of Vericred in a published announcement.

Medgadget had a chance to get a few more thoughts from Michael on the new service.

 

Medgadget, Mike Batista: What are the pain points creating a need for provider-network notifications and how did Vericred identify them?

Michael W. Levin: There is substantial churn in provider networks meaning that with great frequency providers join while others will leave. When a healthcare provider leaves a health plan’s network, patients who have been seeing that provider under the coverage of their plan are likely to be surprised the next time they visit that doctor. Imagine getting to the pediatrician with a sick child only to find out that the is doctor no longer accepting your insurance. The choices are grim: find a new doctor, which takes time or leads to an ER visit, or pay out-of-network costs which can be devastating. This problem is endemic throughout the industry.

Vericred identified the problem as a result of its work with provider-networks and speaking with clients who use Vericred’s data to power “provider-centric search.” Provider-centric search is the ability to enter your preferred doctors and facilities as part of your health plan search or shopping experience and immediately see who’s in and who’s out of each plan. What we heard from our clients was “what happens if the doctor drops out of the network mid-plan year?” While we cannot affect whether or not a doctor joins or leaves a network, we can bring transparency to the changes in these networks. And thus, the development of provider-network notifications.

Importantly, these notifications can be delivered to the individual through the platform from which they purchased the insurance as well as through apps that help them make better use of their insurance or benefits. That may be a public exchange, a digital broker, or an employer benefits administration system. Our goal is to make our solution as ubiquitous as the problem so that never again is someone surprised about whether or not their doctor takes their insurance.

 

Medgadget: There are a number of businesses and technologies that can take advantage of this new data. Can you summarize the benefits to patients, providers, payers, and employers as a result of the new notification capability?

Levin: By proactively notifying individuals that their preferred providers no longer accept their insurance, the element of surprise is eliminated, benefiting all parties. With alerts, the individual can find a new provider before an emergent need leaves them with few good options. Notifications can also be used to alert an individual when a provider they identify enters their plan’s network. This would come into play if an individual enrolled in a plan that didn’t cover one or more of their doctors (perhaps for cost reasons) and later that doctor joins the network. Wouldn’t it be great to get a text or an email saying “Dr. Jones just joined your plan’s network”? In the absence of alerts that individual would likely not revisit the doctor’s participation in the network and therefore not get the benefit of knowing that she can now go to that doctor.

Providers don’t have the awkward exchange with their patient indicating that they no longer accept that insurance. Payers create a better member experience by eliminating surprise and they can reduce costs through avoidance of the administrative burden of dealing with a member who is surprised and upset, and higher costs when ERs are used as a fallback. For employers, notifications are a feature that leads to a better employee benefit experience.

 

Medgadget: Vericred’s new offering takes an important step forward towards more provider network transparency. What is another challenge with transparency in healthcare that still concerns you today? Is anything being done to address that challenge?

Levin: Transparency around the cost of healthcare services and drugs remains elusive. With more individuals being covered by high deductible health plans, there is a need to understand healthcare costs and be able to make informed decisions around cost, quality and availability. Good work is being done in this area through all payer-claims databases, but using such databases is like trying to see intro a room through a pinhole in the door.

Link: Vericred…