Streamlining Provider Management: How Medallion is Revolutionizing Healthcare Compliance

Over the past decade, the healthcare industry has become significantly more digital, yet many important compliance systems that power the industry remain manual — paper forms, faxes, and phone calls. This lack of technology causes bottlenecks for growing players in the healthcare space as these systems collectively present a barrage of time-consuming administrative tasks.

Here are a few hypothetical examples to illustrate the bottlenecks:

Consider a provider group, ExampleMD, which has thousands of providers (licensed medical professionals).

(1). ExampleMD wants to add a provider named Dr. John. It might seem as easy as hiring a new employee, but there are additional compliance tasks. Dr. John must credential with ExampleMD, meaning Dr. John must prove his medical legitimacy by providing an array of certifications, licenses, identifiers, and other credentials to the provider group. ExampleMD then verifies the information with each corresponding source of truth (such as the educational institution where Dr. John received his degree and the state medical board) to confirm that Dr. John has the necessary qualifications to offer medical care to patients. It is time-consuming for ExampleMD to independently gather all these qualifications from Dr. John. Usually, providers and provider groups use a platform called CAQH that allows providers to enter and store their credentials in a single, standardized online profile. After ExampleMD gathers Dr. John’s credentials (either directly from Dr. John or through his CAQH profile) and verifies that the information has passed all the compliance checks, ExampleMD can accept him into the group. However, even after Dr. John is accepted, ExampleMD must constantly monitor his credentials to ensure they have not expired.

(2). ExampleMD wants to contract with a payer (a commercial or governmental insurance entity like Aetna Health or Medicare) to increase the number of in-network patients the providers of that group can serve. Each payer typically has its own specific set of credentialing and verification requirements, which ExampleMD must provide on behalf of each provider. And just like the first example, in order for the provider to stay enrolled in the payer’s program, each provider must maintain valid credentials.

(3). ExampleMD aims to offer virtual care in all 50 states. Each provider must receive the necessary medical license from all 50 state medical boards. This can be a slow process, as each provider must license with each state medical board. And again, just like in the last two examples, ExampleMD must monitor the providers’ credentials to ensure they remain valid (or else they won’t be able to renew the provider’s license).

While this type of credentialing might be manageable for a small team of providers, for a group of thousands of providers, it is a time-demanding process — especially when considering that ExampleMD must monitor each provider’s verifications to ensure continuous validity. Hopefully, the examples above highlight some of the bottlenecks in how provider groups — and any other entities that handle provider management — operate in the healthcare system. But what if those administrative tasks could be abstracted away, leaving more time for healthcare companies to focus on providing quality care to patients?

(drum roll please)

Medallion offers a solution! Medallion is a provider network management platform that streamlines these administrative compliance tasks. Let’s take a closer look at exactly which entities Medallion works with and how they streamline the compliance tasks in the aforementioned examples.

Medallion serves four types of entities:

• Provider groups (entities consisting of healthcare providers, such as primary care physicians)
• Payers (commercial and governmental insurance entities like Aetna Health or Medicare)
• Health Systems (organizations that manage the infrastructure and overall coordination of care for providers/provider groups)
• Digital Health Companies (companies offering services that connect providers with patients, like Hims)

The one thing these entities all have in common is that they handle administrative tasks related to providers.

Let’s revisit the three examples, this time using Medallion to abstract away and speed up the processing of the aforementioned administrative provider management tasks.

(1). ExampleMD wants to add a provider named Dr. John. They use Medallion to gather the provider verifications (certifications, licenses, identifiers, and other credentials) — through a provider onboarding form alongside Medallion’s seamless integration with CAQH mentioned earlier — then verify those credentials with the appropriate sources of truth. With Medallion, it only takes 4.3 days on average to onboard providers. And afterwards, Medallion monitors the providers’ verification statuses on behalf of ExampleMD to make sure the verifications remain valid for Dr. John to continue providing care to patients.

(2). ExampleMD wants to contract with another payer (a commercial or governmental insurance entity like Aetna Health or Medicare) so they can increase the number of in-network patients that providers can care for. Since each provider enters and stores their verifications inside Medallion, ExampleMD can easily enroll the provider — using the existing verifications — with the payer of interest. Depending on the payer, there may be additional information to collect from each enrolling provider, but most of the verifications already exist in the provider’s profile on the platform. Through its efficient data management and enrollment, Medallion slashes payer enrollment time by 50%.

(3). ExampleMD wants to include tele-health services, offering virtual care in all 50 states. Since each provider enters and stores their verifications inside Medallion, ExampleMD can now reuse those credentials to license a provider with the appropriate state board. Licensing a provider becomes as easy as pressing a button, with Medallion handling the rest. Medallion offers full transparency, sharing progress updates, roadblocks, and estimated steps remaining to completion. After the license is granted, Medallion monitors the renewal dates and sends reminders to ExampleMD when it’s time to renew a provider license.

Overall, Medallion abstracts away administrative provider management tasks, leaving their partners with more time to focus on patient care. Medallion has saved over 500K+ hours of administrative tasks through provider credentialing, monitoring, state licensing, and payer enrollment. With plenty of space to grow, it will be exciting to see how they continue to innovate in the healthcare space!

Disclaimer: The views expressed in this article and the information provided are for general informational purposes only and should not be considered professional advice. While efforts have been made to ensure accuracy, the author makes no guarantees.