Hello, everyone. This is Jacob Emerson with Becker's
Health Care. Thanks so much for tuning in
to the Becker's Health Care podcast, where today
we're gonna be talking about navigating network compliance
and the top trends, value, and outcomes.
So joining me for today's discussion is Gianni
Aiello, who is the vice president of product
at Verifiable. Gianni, thanks so much for taking
the time to be with me on the
podcast today.
Yeah. Thank you, Jake. Absolute pleasure to be
here. Excited for the conversation today.
Likewise, Gianni. And before we dive into that,
can you tell us a little bit more
about yourself in terms of the the work
you do at Verifiable
and the role that the company plays within
our health care system?
Yeah. Sure. So, for the audience here, my
my name is Jenny Hagan. I'm VP of
ProductVerifiable,
and I've been at the company now just
over 18 months.
But over the past 15 years, I've been
a product leader at various different technology companies,
including identity security and AI based voice to
text solutions,
both of which that served health care customers.
So have a pretty extensive background in in
serving health care organizations.
At Verifiable,
my role sort of centers around advanced our
mission
to become the autonomous system of record verified
provider credentials.
We really wanna streamline
the often as as I think most people
can understand the complex and
sometimes resource intensive process in health care around
credentialing,
and we really want to divert those that
that resource back to patient care. So we're
that's sort of our primary mission.
I'll sort of end with, like, we we
believe that partitioning facility credentialing and monitoring shouldn't
take weeks or months.
It can be done in hours or even
minutes.
And, I think achieving that is is going
to be about embracing technology, but also rethinking
the way about the way way in which
we go about doing some work. So, yeah,
that's a little bit about me and and
our mission at Verifiable.
Fantastic. Well, appreciate you filling us in there,
Gianni. And as you know, compliance is crucial
in maintaining
trust with patients and organizational
integrity.
So to get us started, can you explain
the core components of a successful network compliance
program
and the trends that you're seeing today across
the landscape?
Yeah. So there's sort of a varied perspective
in the market
around, like, what does what is needed for
compliance. There's a lot of different elements to
it. I'm I I obviously, given our focus
is very credentialing centric,
I'll I'll lean that way, but there are
things that are very adjacent
to compliance around things like network adequacy
as an example,
and, this the timing delivery of claims reimbursement
that are that are part of a a
compliance
solution as well.
But I'm gonna talk about sort of the
the high level fundamentals that I think that
make, a good compliance program irrespective of, like,
the core mission of or the the use
case that you might be solving within the
scope of compliance.
So I would say that the first step
is really about data sharing and onboarding.
There's always a step around how data is
being shared between
a provider organization and a payer organization,
and that's often an area of friction.
Rosters are a good example of, like, a
data point or a a a format
of data that's exchanged between organizations,
and and having that exchange be as frictionless
as possible is gonna be critical.
The second step is, unsurprisingly, process automation.
There is a lot of still manual activity
that goes on in the process
to exchange information,
to validate and verify information,
and then ultimately make decisions on that information.
And so we believe that, you know, there
there are some really compelling ways to to
really better manage that that process,
and and we think that customers need to
sorry. Organizations need to drive towards that.
And the first step is, like, an efficient
and streamlined this is more specific to our
world, like, credentialing process.
We really do think that's sort of a
starting point in the journey around compliance,
around practitioners and facilities.
Without having a credentialed facility or practitioner, you
can't really get onto the other sections
of compliance. And so having good packet creation,
a focus committee review that focuses on risky
cases versus
everything that's coming through the organization
is very important.
And 2 more steps. The 4th step would
be just provide them facility risk management. Like,
okay. You've done credentialing,
but that isn't where it ends. Right? A
compliance program is an ongoing
it's a program for a reason. It it
needs ongoing monitoring. It needs ongoing management.
So how do we make it so that
as things change,
practitioners change, facilities change,
how are those risks being serviced in a
way
that makes the distribution
much more straightforward and
ultimately reduces down any potential liability concerns that
might come from an issue that arises.
And then last and certainly not least is
just then then there is a a a
network effect. Once this data is there, once
it's available,
how it can be distributed into other parts
of the process, and sometimes it's not even
compliance related processes, honestly.
It could be something like just
when do you unlock a specific provider
from being available to for for claims reimbursement
as part of an insurance plan. Like,
the compliance program should be the arbor of
that decision,
and making sure that the system is interchangeable
and quick to to allow that downstream system
to to consume that context
is really critical. So that's sort of the
5 steps that we see, that are really
important to a successful compliance program.
Understood. And I appreciate you sharing those 5
steps with us, Gianni. To follow-up with you,
based on your experience and based off what
verifiable
is seen, ultimately, what's keeping payer organizations
from effective network compliance?
What are some of the barriers that that
they're facing?
Yeah. So I think there are there's gonna
be a bit of a theme in some
of my, like, my my thoughts here, I
think. I think there's, like, an organizational
reality, like, a business relationship
thing or barrier, and then there's a technology
barrier, and I'll talk about them both a
little differently.
So when it comes to the sort of
the organizational barrier, you know, we are finding
that there is a lack of efficient data
sharing and collaboration
between providers and payers in the industry.
The relationship between these stakeholders often feels siloed
with significant walls
that need to be broken down, honestly. Like,
it's it's a real problem.
And without that partnership and streamlined process, compliance
becomes
really burdensome for everyone involved.
Like, a major issue is the absence of
an agreed upon standard for data exchange. Providers
are often required to navigate,
like, unique payer specific requirements for sharing information.
Those requirements vary not because of, like, any
meaningful difference in policy,
but due to each payer's interpretation of those,
those tasks and rules.
So these differences aren't helping sort of anyone
from an insurance perspective, like, drive differentiation. This
is not like a a reason why organizations
are differentiating.
And so we really do need to break
down that barrier
because, you know, we do see we speak
with we we fortunately serve both sides,
and providers are having to deal with, like,
15 different roster templates for different insurance companies.
And they're having to provide different information, which
means that data can sometimes get out of
sync and and or different. And then on
the on the insurance side, that means they
also have to understand that the product the
provider might be presenting information in incomplete formats.
So that's one area. It's not really about
technology. It's about, like, agreeing upon a set
of principles, and I know that this is
probably not this has been talked about for
years.
But and, honestly, until this gets resolved, this
is gonna continue to be a real big
challenge for a lot of organizations.
We need some collective,
decision making to to really break down that
wall. I did wanna pull out that, like,
we do also see that there is a
real need on the technology side to just
embrace more digitization. Like, I'm not we can
we'll talk I'm sure we'll talk about that
in in as we continue here. But, obviously,
the more you can leverage Ditto assets and
you can leverage more,
electronic communications is going to drive much more
efficiency here. And that's not just a statement
of insurance and provider organizations. That's also the
government and others that are the arborists of
this information. And so we have to modernize
in a lot of areas the technology stacks
so we can become more efficient.
Absolutely. And let me let me go back
to your first point there, Gianni, about data
privacy
because we're we're constantly seeing the health care
industry, both payers and providers, have to constantly
deal with evolving laws and and regulations in
this space.
So how would you say that payers should
be evolving their compliance programs with those evolving
regulations?
And then to follow-up with your second point,
what's the role that digital transformation
can play in that?
Yeah. You know, evolving data proxy laws
and regulations, I've I've I've been in another
set sector, which is more about identity regulations.
And so it's always an ever changing,
benchmark. Right?
But I think when it comes to digital
transformation and compliance programs, you know, a digital
footprint allows organizations
to easily track where data resides and how
it's stored and who is who has access
to it.
This level of visibility is almost impossible to
achieve in a lot of the manual physical
data management processes that sometimes still exist today,
in particular where there's exchange between different services
organizations around credentialing and managing these processes.
So, like, with the right technologies, payers can
control access,
enforce robust security measures, and and most importantly,
maintain sort of a detailed audit trail to
track who is who is accessing or modifying
this sensitive private data, right, which is ultimately
where where the regulations are all moving.
This transparency is not only helps in mitigating
risk, but also ensures compliance and evolving regulatory
framework. So if you have this benchmark and
this foundation,
it becomes much more straightforward for you to
adjust as as the benchmarks change.
You know, at Verifiable, we take this step
further by providing sort of a deep audit
trail across our platform.
These trails sort of track every instance of
data manipulation or access who have made the
change,
what was altered and when it occurred, And
that sort of is the information that you
need to be able to present in reports
to anybody that is gonna be reviewing your
privacy,
regulations or or policies internally to make sure
that you're you're keeping in line with those
things and you don't expose yourself to additional
risk.
We also align with various accreditation bodies like
NCQA
around their expectations around handling,
as well as joint commission and others to
make sure that we're sort of meeting their
minimum bar as well around the tracking of
information as well.
So, Johnny, let's talk about the ROI piece
of all this. Obviously, it's it's important to
create buy in on on new digital transformation
projects.
Can you share some examples for us in
terms of short term and long term KPIs
that you and Verifiable consider critical for a
successful network compliance program.
Ultimately, how can the leaders listening in right
now measure their success in this space?
Yeah. Obviously, we we we deal with a
lot of different customers
and organizations with actually varying different needs.
But there are some sort of consistent perspectives
here that we we do see irrespective of
use case. And so in the short term,
I think the most immediate ROI does tend
to came come from an I don't think
it's a surprise sort of efficiency gains internally.
For example, our platform is incredibly efficient at
performing primary source verifications and completing them in
seconds.
That translates to significant time and cost savings
for internal teams
that allows to freeze them from a lot
of the repetitive tasks that they have to
do there. It also improves the organization's risk
posture because many customers were, you know, conducting
as many as
weren't even conducting certain verifications on Like, they
were just didn't have the capacity to do
it. So that leaves them exposed,
when it comes down to,
how they measure. Risk is always a more
challenging ROI to measure. It tends to be
like, what is the potential liability risk, which
honestly, based on some of the cases that
are out there, we're talking 1,000,000 and 1,000,000
of dollars of potential
liability risk. But there is real tangible efficiency
gains that you can build an ROI model
around in just internally
around your team and how much more efficient
you can be with certain digital transformation automation
being put in place.
In the long term,
I think ROI is often seen
in in sort of the speed and fluidity
fluidity of data availability across the organization.
So one of the inherent challenges is when
you have sort of a bunch of disparate
silos of data, you become much more inefficient
in being able to
flow through different scenarios and use cases,
across the organization, and that creates sort of
a rip ripple effect.
We do see that these improvements lead to
better you know, if if you solve the
fluidity of data and how it can also
be exchanged, so if you have a centralized
data store where data is being shared across
the organization
and and it's and it's accurate,
it leads to better member sentiment and stronger
network adequacy, which you can measure. So you
can actually tie
member sentiment around things like your provider directory
or the outcomes that you're driving from network
adequacy
to the
improved efficiency of the collection of provider and
facility information in a centralized store. And so
we think that's another interest in our AI
model that's a little bit more centered around
the the member
that is a more of a longer term
play that once you get to a solid
base, you can start to showcase the the
tangible impact you're having there. So I think
those are the sort of the primary areas
I'd say. Efficiency gauge is obviously risk posture
are the 2 short term. Speed and fluidity
of data and and drive it towards member
sentiment and network adequacy would be the more
longer term place.
Understood. And clearly still a lot of ongoing
challenges in terms of network compliance success.
But in that vein, Gianni, if you were
looking ahead into your crystal balls as we
enter a new year,
what's one thing that you want health care
leaders to be prepared for? And can you
share some of the best practices that you've
observed in your work with health care organizations
all over the country?
Yeah. I'm gonna I'm gonna probably, talk about
2 things versus 1,
cheat a little bit, because I do think
that they're sort of I I've sort of
touched it a little bit throughout,
to to answer some of the other questions,
but I think there are sort of 2
areas to think about, honestly. 1 is sort
of, like, leadership and organizational approach and some
of the things that we observe with partners
and organizations that we're working with and and
and seeing success with. And then there's sort
of the technology
lens that I'm sure is sort of given
my role and and what I represent would
be what people would expect me to answer
on. So I'll start with the leadership and
then land on the technology. So
I I think leaders who are achieving meaningful
wins are those who sort of embrace the
reality of digital transformation
as an iterative journey
rather than a one and done overhaul.
We find that success
the the most successful companies are focusing on
incremental improvements in specific areas and coming back
to sort of my 5 steps. Right? We
have a number of customers that are, like,
very focused on, for example, either the credentialing
packet creation
or the risk posture management on the compliance
side, so the monitoring portion of it. And
they they're they're very focused on that and
getting that into a better place,
as step 1, and and showing results
as an example.
And so
I mean, that's a really,
a critical thing, and we've seen that there
are customers that are in contrast to the
embark on on a more monolithic project approach,
where they're attempting to completely reimagine the process
in one go
and often face significant changes or they tend
to fail, honestly, to meet their goals. We've
seen the approach work firsthand with 1 customer
that I I unfortunately, I can't I can't
state, but they're a very well known,
insurance company, and they sort of become a
beacon for this iterative methodology, and the result
speaks to themselves. I think they've seen massive
improvements in team morale
across their compliance credentialing teams.
They've seen measurable improvements in their key performance
indicators and their focus areas, and they've ultimately
seen,
operational success as well. They've been able to
achieve quicker time to value, and and they
were able to realize their ROI model that
presented the budget to go and do what
they did. So and they did it through
not trying to do everything, and and I
think that's a really important thing
that surprisingly still isn't always embraced, which is
why I bring it up. Like, the amount
of times we deal with customers that are
trying to just reinvent the entire process
from scratch, and FAO is sort of it's
surprising that it still occurs.
On the technology side, I think well, honestly,
I'm not someone that I'm not the type
of product leader that gets excited about technology
for for for its own sake.
I do think it's impossible to ignore the
impact of automation and AI
and what it will have in how you
go about doing network compliance.
In particular around credentialing, it it will change,
how work is done. And I think leaders
who embrace these tools are better positioned to
drive meaningful results.
And a network compliance involves many manual and
time consuming tasks that don't really add a
ton of, like, man like, don't require a
lot of, like, critical understanding of things. I
I, you know, for example, I I can
perform these tasks not only more cost effectively,
but often with higher accuracy than traditional approaches.
And and we're seeing that, like, you know,
at Verifiable, we're particularly excited about the potential
of AI to address 2 sort of critical
areas. 1 is in the data onboarding process
where I can help highlight required data based
on provider types. So whether it's an MD
that's being credentialed in MP or RN, we
can do a much better job leveraging AI
and to and calling out gaps or areas
that we think need to be adjusted
based on our understanding of the datasets that
are out there and being more proactive.
And that's something that's just
not meaningfully
valuable in comparison to a production specialist that
needs to evaluate the entirety of the information
and make critical decisions around how information is
presented to the committee.
Another example would be, like,
AI holds promise in in the reviewing of
adverse actions,
that are associated to,
a credentialing process. So when there is a
discrimination or something that occurs during
normal business work hours, how does AI generate
summaries and highlight key points so that the
committee can be more efficient and the decision
makers
are more effective in that decision making versus
having to go through a lot of additional
details around things that sometimes is not necessary
to the through the context of the decision
being made. So I think they're the 2
sort of big areas that I'm really excited
about and areas that I'm I I hope
leaders embrace because I think that's gonna lead
to to the best results for them over
the next, couple of years.
Wonderful. Well, it's a lot of great advice
and I think a great place to leave
things. So, Gianni, thank you so much for
taking the time to sit down with us
and for sharing your insights with our listeners.
We truly appreciate
it. Yes. Thank you, Jacob. Pleasure.
I'd also like to thank Verifiable for sponsoring
today's episode. You can tune in to more
podcasts from Becker's Healthcare by visiting our podcast
page at beckershospitalreview.com.