Provider Data Modernization

The challenge

During a regulatory-driven business process as a service (BPaaS) transition, a health plan needed to replace its claims platform while managing rapid provider network growth. Provider data was fragmented across multiple systems, inconsistently maintained, and governed informally—creating risk to claims stability, member access, and regulatory compliance.

The solution

DocMe360 delivered a two-phased provider data modernization and migration program anchored in standardized management artifacts. A minimally viable, claims-safe solution was deployed first, followed by iterative enhancements, ensuring operational continuity while building a durable enterprise foundation.

The multi-system transformation included the provider data system of record, claims, care management, contract management, FHIR-based directories and portals, delegated roster intake, and additional downstream consumers.

Our approach

Key controls included:

• Standardized provider intake and maintenance workflows
• Data quality checklists and validation rules
• Provider readiness gates for downstream consumption
• Exception classification and remediation
• Reconciliation and reporting

These artifacts enabled repeatable, auditable, and scalable execution across teams, vendors, and systems.

Results

The initiative delivered enterprise-scale, measurable outcomes:

• Reusable, governed provider data outputs across multiple platforms
• 110,480 provider records built and transmitted across downstream systems
• 98% post-migration provider data accuracy through standardized validation
• Provider-related claims failures reduced from 16,000 per week to fewer than 500
• Delegated roster processing reduced from days to hours
• 98% accuracy achieved in closed-loop PCP data flows

Impact

By anchoring modernization in standardized artifacts, the organization shifted from reactive remediation to proactive control. Provider data became predictable, auditable, and trusted—stabilizing claims operations during a critical BPaaS transition and establishing a scalable foundation for future regulatory, automation, and analytics initiatives.