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Payer Provider Portals: What They Are and Why You Need One

By 07.13.21
Reading time: 4 minutes

As a payer, you know that your contractual relationships with different providers can be complicated. (Understatement of the year, right?)

You’re dealing with different lines of business, government regulations, tangled provider relationships, and payment schedules that can be wildly different. 

What you need is a health insurance provider portal powered by Salesforce to bring it all together. Here’s why:

Making the shift to value-based care

Providers today are shifting their care models to value-based care, focusing on improving the quality of the patient experience as a whole, not just mitigating symptoms. This means patients expect providers to deliver personalized, targeted care and information—and that providers will expect payers to do the same.

How that works for payers is that you can offer incentives and risk-sharing opportunities for providers as their patients get healthier, be more transparent with your pay structures and fees for patients, and put the patient at the center of your operations, even if you’re not in front of them every day the way providers are.

It’s about asking providers to take on more responsibility to ensure they’re managing your member’s care by keeping a strong relationship with them.

Giving providers one place to see it all

Put yourself in your provider partner’s shoes. Physicians may contract with big payers like Anthem or Cigna, or smaller regional payers. The point is, you’re not their only payer. They have to juggle multiple logins, confusing websites, and different systems for:

  • Credentialing 
  • Managing patient needs, like referrals
  • Pre-authorization requests and approvals
  • Claims inquiries
  • What services are covered and what aren’t
  • Appeals and grievances
  • Regulations and privacy

It gets messy real fast. While there is not one singular health insurance provider portal for all payers, you can make a difference.

Those payers offering an effective, intuitive, and efficient provider portal will better serve their network providers and member population. Pairing Salesforce Communities (portal) with Health Cloud ensures everything is in one place, from member data to communications to recruitment and referrals. 

Take onboarding, for example. This is another process that can get complicated with new providers, especially since they’re probably onboarding to other payers at the same time. With a health insurance provider portal, you can have them submit their application to be part of the network and automatically move the process along through Health Cloud, going through the credentialing and contracting process smoothly and efficiently.

Lastly, self-service capabilities within the provider portal enable providers to view claims and submit pre-authorizations, referrals, and appeals all in one place, without needing to get on the phone. This one-stop shopping experience improves the efficiencies and satisfaction for providers, lowers the inquiries into the member services team, and increases the timeliness for authorizations, referrals, and appeals processing.

Building a better patient experience

Ultimately, healthcare is about delivering the best possible care to patients.

Today’s patients demand more from their healthcare providers, and from their insurers. Customer expectations continue to add pressure to healthcare organizations to deliver care with speed, convenience, and personalized service. They expect a level of transparency about how much things will cost, what’s covered, and their benefits, whether they’re going in for a routine procedure at the doctor’s office, filling prescriptions, or dealing with a chronic illness.

And they want it fast. They don’t want to get on the phone and wait on hold for hours—they want to find the information they need quickly, especially if they’re trying to make a decision at the doctor’s office. Payers need to change their approach with members.

Consumers are tired of the experience they’ve had to deal with over the last few years. It’s time for a change, and that starts with a streamlined provider portal that can deliver all of that information and more to your providers on behalf of your members.

Using Salesforce Health Cloud and the provider portal, you can collaborate directly with providers to provide an overall better standard of care. Rather than make care coordinators and providers chase around different platforms for different services, use one holistic portal to keep it all in one place. Integrations with legacy claims platforms or vendor partners, such as those providing electronic medical record software solutions, increase the value considerably by providing all of the necessary patient level data to the providers.

What does that look like in action? You can have a doctor seeing their patient with a laptop or iPad to get their electronic medical record (EMR) as they’re speaking with them. They can see what lab work has already been done and order new tests that the patient can take the same day, knowing the cost to them ahead of time. Once the patient arrives at the lab, that technician already knows who they are, which tests were ordered, and when a patient can see the results.  In addition to the reference above, providers can immediately be notified of gaps in care and lack of adherence to medication based on claims data.  

Healthier patients = lower claims costs

The healthier patients are, the lower the claims costs will be. This, in turn, can lower premiums for the individual and fully-insured markets while building a positive payer/provider relationship that is a win-win for everyone.

That kind of seamless care follows the patient through their healthcare journey, and it gives the entire care team a better incentive to keep the patient and member as healthy as possible. 

Create a 360-degree view of the healthcare ecosystem with Silverline

You already have Salesforce? Adding Health Cloud with tools such as the provider portal will make it much easier for you to do business. Add Salesforce Industries to the mix for provider network management and you’ll be able to easily handle every element of the payer/provider relationship.

It’s more important than ever to consider cloud implementations like Salesforce Health Cloud coupled with the provider portal to build a 360-degree view of members and providers, so you can deliver high-quality services and help your provider partners do what they do best: take care of their patients.

See how Silverline can help your team transition to value-based care with ease. Talk to one of our healthcare experts to learn how Silverline can help.

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