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What is provider network management, and why is it needed?

Maeve Wiley
What is provider network management, and why is it needed?

Payers are a crucial component in healthcare delivery, and they have to ensure that patients get timely care at the right cost. Those who opted for payer management network solutions from custom healthcare software development firms can function smoothly—those who haven’t yet faced the brunt of paper-based processes and repetitive tasks.

The deployment of provider network management solution software for insurers is vital as it helps them manage their healthcare provider networks efficiently. They can process claims with percent accuracy, which has helped them reduce costs and work with healthcare providers to reduce administrative overheads.

What does a provider network management solution do at the fundamental level?

  • A provider network solutions collects data from multiple healthcare ecosystems. These could be internal or external systems. A provider network management solution can then use this data to provide a central system.
  • The consolidated data can pertain to patients’ lab results, medical claims, authorizations, care plans, and treatment schedules. The consolidation of data saves time for businesses because there is no time lost in fetching data from multiple systems.
  •  Provider network management software can also use automated processes to notify patients by sending reminders, requesting appointment confirmation, and providing patients with up-to-date information.
  • A centralized system provides consolidated health plans, processes, fees schedules, and regulatory compliance information.

What factors are prompting payers to look for provider network management solutions?

Patient Protection and Affordable Care Act (PPACA) is a healthcare mandate that payers need to comply with, including its Administrative Loss Ratio and Medical Loss Ratio criteria. Payers have to find ways to improve their organizational efficiency, reduce operation costs, improve benefits coverage, and improve customer satisfaction benchmarks.

PPACA will cover all citizens in the United States eventually. PPACA criteria such as Medical Loss Ratio require insurance payers to allot 80 and 85 percent expenditure on individuals, small group markets, and large group markets to improve healthcare and medical care quality. The rest can be allotted to administrative expenditures. Such events and policies make insurers use provider data management and provider network solutions to reduce costs and improve efficiencies.

How has advanced data analytics of provider network management solutions helped payers?

The healthcare industry’s dynamic nature makes payers face stiff challenges in maintaining and managing provider networks and medical loss ratios. Payers utilize advanced IT data analytics via the provider network management solutions to reduce administrative overheads. Payers leverage insights to implement strategies that help them retain existing members and design effective care management roadmaps.

Analytics techniques such as clustering, unbiased predictive modeling, optimization, and score-based propensity shaping are used to form analysis. Quantitative and statistical analysis tools are being applied to data in tandem with predictive models to establish facts based on data. It helps insurers use these insights to make critical decisions such as provider contracting.


Payers can use a custom software development firm to build a customized provider network management solution. Custom provider network management healthcare can be cloud-based, on-premises, or hybrid. Supporting systems, including mHealth apps, mobile technologies, remote patient monitoring technologies, etc., can be created. 


Maeve Wiley
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