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AHIP pilot program aims to improve doc directories


An accurate account of your provider roster is essential to driving value-based care, according to one expert.

America's Health Insurance Plans (AHIP) is initiating a pilot program to ensure that physician directories are more timely.

Read: Critical mistakes to avoid in value-based payment models

The pilot is designed to facilitate one primary point of contact for providers when updating or reporting changes to their practice information, such as their location, specialty, whether the practice is accepting new patients, insurance network status, and medical group and hospital affiliations. The pilots will also incorporate recent regulatory changes related to network directories? For example, new Medicare Advantage requirements for 2016 require quarterly outreach to providers to verify key provider directory data.

According to an AHIP fact sheet, the pilot program, which will run through September, involves two directory vendors, BetterDoctor and Availity, and will include providers in three states: Indiana, California, and Florida. Twelve health plans-including Anthem, Blue Shield of California, Cigna, and Humana-will be participating. More than 100,000 providers are expected to take part.

Providers benefit by having one primary point of contact for inquiries for changes, rather than receiving requests from multiple health plans, AHIP said.

IzaguirreThe need for accurate and timely provider data has never been more critical, says Alexander Izaguirre, PhD, MBA, founder and CEO, Aprenda Systems, LLC.

“Today more consumers are shopping via the internet through tablets and smartphones,” says Izaguirre. “This has motivated healthcare organizations to develop technology friendly versions of their products and services. Providers participating in numerous plans, provider groups, societies and professional networks struggle to keep up with requests to update their data often leading to unresponsiveness.”

As a result, many organizations have resorted to acquiring provider data through access from trusted partners, purchasing data from data re-sellers and web scrubbing, Izaguirre says.

“Since changes are frequently occurring between update intervals most organizations can claim they have accurate provider records for a brief period of time at best,” he says. “To complicate matters, the collection of provider data from various organizations are rarely synchronized within or among organizations and lead to more data disparity. There are many provider directories and millions are being spent to create and maintain them.”

Next: The cost of maintaining


Unfortunately, according to Izaguirre, most are costly to maintain and remain inaccurate.

“The underlying processes that support these products and services originate from manual inefficient processes that have always generated some errors,” he says. “In the past, the rate of errors has been manageable with the staff on hand. At its core all computing technology does is expedite pre-existing processes. When computing technology is layered over an error prone process the affects are astounding-you generate errors at a rate that staff cannot keep up with. What we are seeing today in the provider directory space is a natural progression often seen in IT. The promise of automation drives the use of technology.”

The unintended consequences from the use of automation drives organizations to revisit ineffective processes and replace them with new processes that minimize errors, Izaguirre says.

The goal of the directory is actually simple, according to Izaguirre: To leverage accurate and timely provider data in order to support a variety of business activities.

“These activities include but are not limited to: Improve plan member access to healthcare through access to accurate provider directories, facilitate coordinated care among providers by furnishing them with accurate peer directories, increase provider participation by shortening the credentialing process, increase operational efficiencies by reducing errors related to bad data and much more,” he explains.

Managed care executives should pay close attention to bad data, in this case provider data, as it has significant cascading affects throughout an organization and most of its initiatives, Izaguirre says.

“Bad data can be defined as duplicate data, conflicting data, incomplete data, invalid data and unsynchronized data. Correcting provider data will improve directory accuracy and timeliness, shorten the credentialing process pay claims faster and more accurately,” he explains.

Accurate directories alone can reduce operational expenses, improve member satisfaction, minimize out of network claims, increase in network referrals, and support value-based care initiatives, Izaguirre says.

“Introducing new ways for providers to furnish their data will not only help address the provider directory challenge but also improve engagement between providers and health plans, health systems, their peers and patients,” he says. “Value-based care initiatives requires engagement of providers. Engagement of providers requires that you first have an accurate account of your provider roster and that it is easily accessible between them.”


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