Inaccurate provider directories create barriers to care

The Centers for Medicare & Medicaid Services (CMS) released a report in January on the accuracy of provider directories, the online lists provided by insurers and used by health plan enrollees to find in-network doctors or select a plan in which their preferred caregiver participates.

Of the 108 provider locations examined, CMS found that on average, 45% of Medicare Advantage physician directories contained inaccuracies, including incorrect office locations and phone numbers, as well as erroneous information on whether a given provider was accepting new patients.

A month after the CMS report was published, the California Department of Managed Care (CDMC) announced that it uncovered its own provider directory problem. When reviewing insurers’ attestations to the timely access of care, CDMC found that 90% of the submitted reports contained “one or more significant data inaccuracies.”

The problem of inaccurate provider directories is both enduring and widespread, and has only intensified as millions of people gained coverage under the Affordable Care Act (ACA).

For health plan members, poor directories not only create barriers to care they also put consumers at risk for unexpected medical costs if they visit an out-of-network physician. For providers, it’s yet another time-consuming data request from the dozen or more health plans with whom they contract.

As for insurers, the data compliance “stick”-in the form of stiff financial penalties and lawsuits-is waved exclusively at them.

In 2015, for example, two California insurers were subject to fines and consumer lawsuits due to overstating their physician networks during the 2014 ACA rollout. And in 2016, new regulations went into effect that allows CMS to fine health plans up to $25,000 per Medicare beneficiary for errors in Medicare Advantage plan directories and up to $100 per beneficiary for mistakes in plans sold on HealthCare.gov.

At the state level, penalties for inaccurate directories can be even stricter than federal guidelines, and because compliance mandates vary by state, the administrative burden for health plans with multi-state networks can be daunting.

A tough nut to crack

At an elemental level how hard can it possibly be to keep provider directories updated?

The question assumes that provider data is largely stagnant and should be relatively easy to maintain. In fact, the opposite is true.

Many health plans still rely on legacy systems where provider data is stored in multiple, disconnected databases. As business requirements have evolved, organizations have implemented incremental stop-gap measures to address data limitations, but these don’t address the core challenge: the lack of a single source of truth.

Therefore, to create directories, provider data must be cross-referenced against multiple systems, which means it’s more likely to contain redundancies and incomplete or incorrect data.

For example, health plans often update provider data annually as part of the contract and credentialing process, using this information to populate provider directories. For providers, documenting this information takes time as a detailed record can track up to 380 distinct line items, including service locations, billing locations, payment locations, specialties, certifications, affiliations, office hours, and languages spoken.

From a standards perspective, it’s not unusual that the provider’s information doesn’t conform to the data structure required by the health plan. Take, for example, whether a provider is accepting new patients. Most health plans capture this data as a binary-yes or no-field, but the reality can be more nuanced. A provider specializing in a certain branch of medicine may be willing to accept patients that meet certain criteria, but not the general population. Or the specialist may be able to accommodate new patients at one service location, but not at another.

Next: A data problem?

It’s a data problem

The root cause of the problem isn’t the directories themselves; it’s the underlying data. Capturing, storing, and retrieving provider data has always been a complex process.

The transition from fee-for-service to value-based payment models creates a need for better communication and coordination between health plans and their provider networks, particularly around the areas of risk sharing and quality measures. To achieve this, health plans and providers need to recalibrate how provider data is collected, stored and updated.

However, recalibration in and of itself can be a challenge. While health plans recognize the limitations of legacy technology, implementing large-scale initiatives to modernize them requires a significant capital investment, which may not be feasible.

So the insurance industry is seeking new strategies to solve the provider data problem. In 2016, America's Health Insurance Plans (AHIP) launched a three-state provider directory initiative to uncover strategies for better collaboration between payers and their provider networks to ensure that information is timely and accurate for healthcare consumers.

The initiative found a need to raise awareness among providers about the criticality of regularly updating their data with the health plans they contract with. Results also indicated a need for new incentives for providers to remain accountable, and a need for additional technical standards to improve communications between health plans and providers.

While aggressive multichannel communication-phone calls, faxes, and e-mails, among others-can eventually procure the desired results, it presents others problems. For example, various departments within a given insurance organization are already in regular-perhaps excessive, some physicians may argue-contact with providers’ offices for myriad data requests.

Now add provider directory requests to the mountain of other data requests, multiply it by the average of 15 to 20 health plans a provider contracts with, and you’ve got an acute case of abrasion and no incentive on the part of the provider be a better collaborator.

A streamlined strategy

In terms of maintaining a healthy provider-payer relationship, the means is nearly as important as the end. Proactively, there are four ways that health plans can improve their internal processes for collecting provider data:

·      Manage data requirements across departments. By understanding how data is captured and used throughout the organization, health plans may be able to streamline processes simply by sharing data that already exists. For example, the claims and network management departments both rely on service and payment addresses. If one becomes aware of a new address, there should be mechanism that alerts the other of that change.

·      Identify key staff members at provider facilities. Different staff members within a provider facility handle different types of information. For example, the person who answers information about claims may not be the same person who handles risk management inquiries. But more often than not, the person answering the main line at the provider office doesn’t know how to route these calls. Health plans can reduce some of this churn by having the name and contact information for key staff members who can handle their request.

·      Rethink data collection. Is it more important to get all the data, or is it more important to get clean data? The answer is both. In the short term it can be tempting to capture the minimum number of data elements required to meet the federal and state mandates. However, health plans should also consider long-term requirements and opportunities for future improvements when building their data schema.

·      . This technology-focused solution can leverage the strength and market participation of many health plans, giving providers a single point of entry and streamlined navigation. Rather than moving between completely different interfaces, providers and their staff have to learn to navigate just one, which then enables multiple workflows. Menus and commands are shared across workflows-and across plans. The goal is to deliver a consistent look and feel, while still giving participating health plans the opportunity to communicate payer-specific information to their networks. Along with a consistent workflows, multipayer platforms allow providers to update demographic information just once and have the data sent to participating health plans. Providers don’t have to manually complete forms and figure out how to submit them, and they don’t have to manipulate their data to accommodate the health plan’s preferred data structure. The benefits are similar on the health plan side, as each health plan receives up-to-date, accurate information in formats that their systems can consume and use. The plans don’t need to analyze submissions to verify that similar but unique specialty names, addresses, or certifications are consistently used. In addition, health plans can greatly improve their chances of getting up-to-date data from providers by making it part of the existing workflow.

Simply improving the quality of provider directories shouldn’t be the goal. Instead, as health plans address the underlying problems of organizational silos, legacy systems, and manual processes, they are making it easier for providers and health plans to share quality and risk information; reducing the number of requests to providers by asking the right person for the right information at the right time; and improving adoption of data management systems by allowing providers to quickly and easily update their demographic information and send it to all participating health plans.

With access to timely and accurate data, health plans are better able to manage costs, improve engagement with providers, and ensure members have the information they need to make informed healthcare decisions.

Mark Martin is director of payer solutions, provider data management, for Availity, and Dianne Wagner is senior director, provider engagement & enablement, for GuideWell.