A “Reputation-Building” Solution:
How an Enterprise Payer Partnered with ProviderTrust for a Compliance Overhaul
In today’s changing regulatory landscape, many payers have come to rely on time-consuming manual processes and hope when trying to manage primary source verifications and exclusion monitoring. This case study outlines how a partnership with ProviderTrust empowered a prominent payer to replace outdated processes with an accurate, single source of truth for primary source verifications and exclusion monitoring.
ABOUT OUR CLIENT
Our client is a prominent Southern payer serving 2.3 million members. Since 2022, this client has partnered with ProviderTrust for monthly credential verification and continuous sanction and exclusion monitoring for a network of 26,000 providers, along with 25,000 employees, agents, and vendors.
BY THE NUMBERS
million members
providers
employees, agents, and vendors
CHALLENGE / SOLUTION
THE CHALLENGE
Like many large payer organizations, our client experienced significant growing pains while manually keeping up with evolving laws and regulations over the years. “We grew up doing what had to be done. The laws have come so fast and so furiously. But it siloed us and created a lot of duplicative work,” said the organization’s Corporate Compliance Officer.
In 2022, our client discovered that their Medicare line of business was not fully compliant. As they looked for the root of the problem, the compliance department uncovered that five separate departments were unknowingly using six different vendors and a mixture of manual processes to verify credentials and primary source verifications. As a result, their efforts were often redundant—and yet, the team found additional areas that had fallen through the cracks after individuals who performed manual checks left the company.
These organization-wide inefficiencies left our client open to costly compliance risks and data errors. On top of the risk of civil monetary penalties (CMPs), these inefficiencies also created significant gaps in internal data accessibility, given the lack of cohesive tools across departments, including Provider Network Operations, Audit, and Compliance.
Our client needed a short-term solution to improve compliance with their Medicare line of business right away, but they also needed a long-term solution to ensure large-scale oversight of all lines of business. The client began to explore how a single automated solution could overhaul their process, circumvent the risk of fraud, waste, and abuse, and ensure complete organizational compliance with state and federal laws.
“Our culture is not bare minimum,” said the company’s Compliance Manager. “We do all kinds of things to prevent fraud, but yet we hadn’t been checking our claims or providers [for exclusions] daily. Those lists change every day.”
Though some members of their organization questioned the idea of automating their primary source verifications and exclusion monitoring processes, the compliance team knew it would result in more efficient monitoring, productive workflows, and improved data accuracy.
“Frankly, the biggest problem was people don't like change,” said the client’s Software Administrator. “They wanted to keep doing things the way they always have been, and it just wasn't working. So we pushed really hard to show them that there's a better way.”
THE SOLUTION
That “better way” involved pairing up with ProviderTrust to fully automate the client’s exclusion monitoring and primary source verification processes. By switching to an automated solution, the client could quickly identify and address gaps in their prior manual monitoring and verification efforts.
“We knew the value ProviderTrust could bring. The more we laid out, the more we knew we needed to do this for compliance," said their Corporate Compliance Officer.
ProviderTrust implemented a customized approach to ongoing exclusion monitoring and license verifications for participating and non-participating networks. Within two months of first connecting with this client, ProviderTrust had implemented exclusion monitoring services for the client’s Medicare network and bridged gaps in coverage to bring the organization into full compliance.
Now, all of our client’s eligibility verification processes run automatically with the help of ProviderTrust’s industry-leading data—plus, stakeholders across the organization can access the data they need in a centralized location.
Our client’s Corporate Compliance Officer says that with the support of ProviderTrust, “You can look your board in the eye and say, ‘We are following the laws, we are following the requirements.’ And then you can look auditors in the eye and say that, and you have proof. That's huge.”
THE RESULTS
Since beginning a partnership with ProviderTrust, our client reports a remarkable increase in efficiency across the organization. Instead of paying for six different vendors to provide incomplete results to separate departments, our client can access ProviderTrust’s industry-leading data in a single source of truth available to all stakeholders. That data includes ongoing monitoring and verification of:
• Federal and State Medicare/Medicaid Exclusion Lists
• Primary Source License and Credential Verifications
• CMS Preclusion List
• DEA Registrations
• SSDMF
• Medicare Opt Out
• NPI Validation
• OFAC
• NPDB
A partnership with ProviderTrust has empowered our client to:
Break down silos between departments with a centralized hub for credential and exclusion data
Consolidate vendor usage with a single solution for credential verification and exclusion monitoring
Fully automate their monitoring processes, eliminating partial or inaccurate matches
Prevent payments to ineligible providers or vendors with immediate alerts and ongoing sanction/exclusion monitoring
Ensure audit-readiness with organization-wide compliance oversight
THE FUTURE
Now that their primary source verification and exclusion monitoring processes are automated, this client can refocus on priorities that improve their bottom line and elevate their member experience. “ProviderTrust is a reputation-building piece of software,” said their Compliance Manager. “It works.”
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