Provider Directory Inaccuracies

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Demystifying the data

There is a significant shift happening in healthcare as the industry recognizes it must focus on improving the patient experience. We see it with the increasing popularity of mobile health tracking tools and wearables; online patient scheduling and payments; telehealth; healthcare shopping tools; and more. Healthcare technology companies, especially, know they must find new ways to ensure patients walk away from each healthcare interaction feeling positive and in control of their own destiny.

Accuracy Importance

All of this focus on patient engagement and empowerment is wasted, however, if the patient encounters a poor experience from the very start of their healthcare journey.

Consider Jane, a working mom looking for a pediatrician in her new neighborhood to treat her son’s ear infection. She logs on her health plan’s site, finds the nearest pediatrician in the provider directory, and takes her son in during her lunch break. A few weeks later, after her son is feeling better, Jane receives an out-of-network bill with a cost significantly higher than what she expected. It turns out the pediatrician was incorrectly listed on her health plan’s provider directory, and that physician hasn’t accepted her insurance since last year!

Recent studies indicate provider directory data is inaccurate and outdated by as much as 50%. That could mean an error as minor as an incorrect phone number, or as major as an incorrect provider listing that sends a patient to a provider who is not in their network. This is a costly and serious issue for patients and insurers alike, which is why CMS is issuing mandates with severe penalties to ensure provider directories are fixed.

The CMS mandates go into effect Jan. 1, 2017, and health plans will face fines of up to $25,000 per beneficiary for incorrect provider directory listings. Several states are setting their own strict mandates, calling for additional fines if the directory is found to have an incorrect listing. Many of those states are requiring updates on a monthly basis, while others are requiring updates on a quarterly basis.

Managing Data

But how can health plans manage the arduous and difficult process of updating their provider directories, while also executing their primary task: managing the very important and sensitive claims data for their members?

There’s an abundance of information patients need in order to make the right healthcare choice for themselves or their families. When it comes to the provider directory, they need to know whether or not the physician is accepting new patients, hours of operation, basic contact information, languages spoken, location(s), areas of specialty and gender. Many patients would prefer to also have the physician’s professional biography, education and credentials, and even a photo. Think of how unsure and frustrated people become when they discover this information is incorrect and out-of-date; this is not the experience any health plan should want for its members.

To manage this, health plans have a lot of work ahead of them. Outreach must be made to each provider’s office on a regular and automated schedule. If a phone number is incorrect, email will need to be used. To make it worse, these physicians and their team are working on busy and packed schedules, so it’s not always convenient for them to return calls. Outreach like this requires a large team and a very sophisticated automated technology that tracks everything.

Once the directory is clean and accurate, plans must continue to sweep the data to ensure it stays up to date on a quarterly or monthly basis. This is especially critical, as both CMS and many states plan to check on these updates regularly. On top of that, providers are changing their listing information, especially phone numbers, addresses, locations, and availability for new patients, on a regular basis.

What’s Next?

The more technology companies can work with insurers to correct and manage these droves of data, the more health plans can focus on doing what they do best: managing claims data and ensuring their members pay the correct amount for the services needed. It’s critical healthcare technology companies get to know what hurdles payers are facing in the digital world, so they can truly help address these gaps.

As CMS and state mandates continue to change, and health plans find their stride, patients will no longer face unexpected out-of-network fees. After reaching a critical point with inaccuracies, changes are made in the right direction, and consumers can start to feel confident their provider directory is truly helping them make the right decisions. Furthermore, physicians can focus on patient retention, knowing their patients are being referred to them by the correct source: their health plan.

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About Author

Dan Medin

Service products director, HealthSparq

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