by April Stiles... Provider directories are often riddled with inaccuracies, burdening everyone who attempts to access this crucial data. Whether it is patients, providers, or healthcare personnel, errors in provider data prove to be a major roadblock for everyone in ensuring network accuracy and adequacy.
A 2016 study by a research group at West Virginia University tested California health insurance directories, posing as patients and attempted to make appointments with 743 primary care physicians listed in California health plan directories. These “secret shoppers” were unsuccessful 70% of the time. *
Without proactive management paired with the right technology, the quality of provider data degenerates quickly. The consequential results accompanied by inaccurate data are as follows: • Records containing errors or missing information • Providers listed that are no longer in network • Duplicate records • Providers with inaccurate or missing National Provider Identifier (NPI) numbers • Incorrect, old, or missing addresses • Incorrect or missing HIPAA-secure fax number • Providers with sanctions • Deceased providers
It is important to understand the potential downfalls of inaccurate provider data in order to ensure that your organization has the best provider data management solution in place. Health plan relationships Inaccuracies in provider data adversely affect the relationship between a health plan and its members. When evaluating the root cause of poor member experiences, many of them can be traced back to erroneous network data. Members rely on health plan directories but inadequate provider data can lead to dissatisfaction and increased healthcare costs.
Health plans require provider data validation to have a confident relationship with their members. The change must start with improvements in the quality of data from plans and providers. Some of the more innovative provider data management organizations are turning to machine learning to optimize data cleansing and roster management. As dataset volumes grow and the data are sourced from more systems, the natural variations that arise require a logic that can become increasingly capable of adapting to the variations that occur naturally.
Exposure to sanctions and lawsuits With faults in provider data accuracy, compliance is at risk. Health Plan and Workers’ Compensation organizations face the possibility of being exposed to regulatory sanctions and potential lawsuits when their data is not accurate.
Regulations on both the Federal and State level are in effect that allow CMS to fine health plans for errors in directory data. Along with regulatory fines, health plans are faced with lawsuits, where consumers are attempting to reclaim damages done to them caused by incorrect provider data. Provider data must be maintained to the highest standards of accuracy to comply with regulations.
Impact on everyday business functions Accuracy within provider data is vital for the success of business. In addition to provider directories, inaccurate provider information impacts many functions of everyday business, including claims processing, network management, compliance, fraud detection, physician recruitment, and communication between healthcare practitioners.
Many stakeholders, including network management, credentialing, and claims processing, rely on provider data for various business and care functions. With accurate data, health plans are able to make decisions that increase efficiencies and minimize costs.
Provider data is exchanged in almost as many formats as there are exchanges. This is complicated by the reality that there is no single set of standards for provider data. A master provider data index can enable a "single source of truth" that can be accessed by all stakeholder.
Price of operational inefficiencies With accurate data being integral in directing members to appropriate care, the contrary ends up being costly. Inaccurate provider data creates operational inefficiencies and sub-optimal networks that cost health plans, workers’ compensation organizations, and health systems billions of dollars each year.
When data is consolidated and up-to-date, gaining access to provider information becomes easier and a better understanding of in-network providers is created.
Impact on care quality Inaccurate provider data impacts care quality. This poses a risk to both members and organizations. In the age of healthcare transformation, provider data plays a critical role. A provider directory serves as a digital storefront that members and consumers enter to begin their healthcare journey. Typical errors, such as wrong phone numbers and failure to remove providers who are no longer in-network make it difficult for members to find the care they need, and starts off a potential member’s relationship with the health plan on the wrong foot. This not only leads to dissatisfaction, but it can also lead to delays in care which can adversely impact overall outcomes..
To ensure data quality, it is important to consider 6 essential elements - completeness, processibility, consistency, timeliness, accuracy, and accessibility. It is important to collect complete provider data from all existing sources and formats to aggregate, map, cleanse, and harmonize for accurate access by internal and external stakeholders and consumers.
Provider data is a critical part of your business, so it is important to find a partner that really knows the industry and challenges you face. As an innovator of provider data management, Perspecta has the expertise and digital solutions to take on the workload more efficiently and effectively, helping you reduce costs, and free up internal resources to focus on other areas of your business.