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Five Provider Data Challenges for Groups


Maintaining provider data has been a longstanding challenge within the healthcare industry. CAQH identified five challenges among health plans and groups and a new solution.

Wires crossed

Maintaining provider data has been a longstanding challenge within the healthcare industry. Accurate data helps patients find answers to questions like, “which doctors practice at my preferred location?” or “what is my doctor’s phone number?” However, the process for collecting and managing this information is not working as it should. 

For example, even though

the industry spends $2 billion annually on provider data

, CMS recently found that 49% of provider locations listed in health plan network directories had at least one inaccuracy.

That is a staggering number, and one that has begun to garner government attention. There are now federal and state requirements for health plans to maintain accurate provider directories, and failure to comply can lead to warning letters and possibly even fines for health plans of up to $25,000 per beneficiary.

Health plans have historically used a number of methods to gather provider information, including regular phone, fax, and email communications with providers, in-person provider visits, online provider portals, and mining internal and external data sources. These approaches are cumbersome, costly, and often result in poor quality data.

Related article: Experts Share How to Apply Big Data to Patient Care

The current disjointed process also places a tremendous burden on providers who may share similar information in a variety of formats on different schedules with multiple health plans. For large group practices and hospital systems where information about many providers is handled centrally, the problem can be exponentially complicated. 

Consider this: The typical group must manage 140 data points for each of its providers-for most groups, that is more than one million data points in total. They then must share that information in a variety of formats and platforms and on different schedules with, on average, a dozen plans. You can understand why poor-quality provider data has become such a chronic problem.

How do we solve it?

CAQH, an industry alliance that works to improve business processes in healthcare, conducted more than 100 deep-dive sessions with nine health plans and 35 groups to understand the problem groups face and develop a new solution.

From its research, CAQH was able to identify five challenges.

Challenge #1: Multiple relationships

Groups work with, on average, 12 health plans, so there are a lot of parties to notify when something changes. Furthermore, due to recent regulatory requirements, groups are obligated to let health plans know when information is unchanged, adding to the noise.

Challenge #2: No standard format

Each health plan requests that groups submit provider data in a specific roster format, which often differs from the format requested by other plans. This means that, for every small change to the data from one provider, the person(s) in charge of submitting rosters must make and communicate this change across multiple files, formats, and systems. Naturally, not all of these changes are executed successfully.

Challenge #3: No standard cadence

To complicate matters further, depending on the contractual arrangement, different groups send provider data to their plans at different intervals-quarterly, monthly, or even bi-weekly. These intervals often occur on different dates for different plans. Some groups then send updates by email to the plan between submissions.

Challenge #4: Manual, labor-intensive process

The current data exchange process is highly manual and relies heavily on email communication. Groups often have no record of whether plans received or viewed their changes and do not know if or when these will be reflected in their provider directory and other business systems.

Plans must subsequently review every file and make manual updates to their internal data systems. Because plans are ultimately responsible for ensuring that the data is accurate, they often perform extensive, manual quality assurance (QA) checks to confirm the information. If plans have questions about the data in their rosters, they must find the original email with the roster file, reach out to the sender, and wait for a response. 

Challenge #5: Difficult to automate

Sharing data could be more manageable if the process were easier to automate. For example, groups would like the ability to pull information directly from their provider data management systems and send it to plans automatically. This would not only reduce the risk of human error, it would free staff to focus on higher value activities. However, a lack of standardization in the way provider data is maintained and shared has made this kind of automation extremely difficult.

Related article: Four essential players for your healthcare data analytics team

For their part, health plans would like data that passes an automated QA process to flow directly into their directories and other systems, also resulting in reduced error and staff burden.  

Where do we go from here?

After analyzing the issue with plans and providers, CAQH brought both parties together to design a solution. The result is CAQH ProView for Groups, which streamlines the data sharing process between eligible provider groups and health plans to provide more accurate and timely information. It is free to provider groups and enables them submit a single file to multiple health plans through a centralized portal, which automatically checks for errors. Participating plans then receive higher quality provider data that can be easily uploaded into their systems and online directories.

CAQH ProView for Groups can be accessed through a provider data platform that most plans and providers already use-CAQH ProView. This program is currently utilized by nearly 1,000 health plan entities and 1.4 million providers to share information.

Simple information like office hours and location, or even which healthcare providers are in-network, should be easy for patients to find and are critical for consumers to identify and access timely, affordable, and high-quality care. CAQH ProView for Groups is a significant step forward in addressing the industry’s provider data challenges.

Atul Pathiyal is the senior vice president, product and strategy for CAQH. He is responsible for setting the strategic direction for a portfolio of industry-wide utilities that address complex and systemic underlying challenges that affect stakeholders across the healthcare landscape, such as provider data management, credentialing, electronic payment enrollment, and coordination of benefits. Prior to CAQH, Pathiyal held roles at a large national health plan as well as in management consulting. He holds degrees from Johns Hopkins and the George Washington University.

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