Hello, everyone. This is Jacob Emerson with Becker's Healthcare. Thanks so much for tuning in to the Becker's Healthcare 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 eighteen months. But over the past fifteen 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 Advance Now 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 and 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 I'm I'm 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 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 credential facility or practitioner, you can't really get onto the other sections 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 two more steps. The fourth step would be just provide them for security risk management. Like, okay. You've done credentialing, but that isn't where it ends. Right? A compliance program is an ongoing program is 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 lastly 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 denturing system to to consume that context is really critical. So that's sort of the five steps that we see, that are really important to a successful compliance program. Understood. And I appreciate you sharing those five 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 arborist 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 like, 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 comp 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, 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, honestly. 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 millions and millions 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 set 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 interesting ROI 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 gains is obviously risk posture are the two short term. Speed and fluidity of data and and drive it towards member sentiment and network adequacy would be the more longer term plays. 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 two things versus one, cheat a little bit because I do think that they're sort of I I've sort of touched on it a little bit throughout, to to answer some of the other questions, but I think there are sort of two areas to think about, honestly. One is sort of, like, leadership and an 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 five 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 one 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 that 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 one 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 in 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 two sort of critical areas. One is in the data onboarding process where I can help highlight required data based on provider type. So whether it's an MD that's being credentialed in NPR end, we can do a much better job leveraging AI until 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 two 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.