The era of getting by with shoddy provider directories is over. As the industry shifts from prioritizing volume-based to value-based care, there’s a profound sense of urgency to cultivate clean, comprehensive provider data.
The costs of poor management can be immense. More than half of U.S. physicians say they encounter patients each month with insurance coverage issues due to inaccurate directories. An assessment of provider locations found an error in roughly half of them. These issues add up to $2.1 billion in annual costs, and can lead to operational inefficiencies, payment concerns, problems with care, conflicts with regulators, and — perhaps most important — member frustration.
A large health plan might have hundreds of thousands of contract providers, with each involving roughly 140 data elements. If a provider sees 25% annual turnover, that means rosters that aren’t updated are, at best, just 75% accurate.
Here’s how data management can help.
1 - Master regulatory requirements
Medicare and Medicaid demand accurate provider information. They perform audits and impose non-compliance penalties. The No Surprises Act, which took effect in January 2022 and protects patients from unexpected medical bills, also brings its own requirements.
Provider directories must be verified at least once every 90 days. Databases must be updated within two business days of a health plan receiving information that a provider has changed networks.
One rule of thumb for compliance is that regulators want to see processes: Is there a process in place to remediate? To handle complaints?
2 - Cleanse data continuously
It might seem hard to generate buy-in for improving provider information, especially because of the overhead involved and the cooperation needed between payers and providers. But with a single source of truth that checks all those boxes, everybody wins.
How much of a provider directory needs to be accurate? Some might settle for 85% to 90%. “That’s a fascinating statement to make if you really think about it,” Rivkin, the guest speaker from IDC Health Insights, says. The key is to make investments that approach cleansing data as an ongoing, long-term priority.
3 - Explain the payoffs
Educate providers on the downstream value of having correct data. “Carrots and sticks” can help: When a provider sees a change in cash flow, either through increasing pending claims or a reduction in reimbursements, that usually gets their attention.