Members rely on provider data to seek and manage care. It’s important to make sure the published information about providers is timely and accurate.

There are important considerations regarding how the quality of provider data is managed, standardized, maintained, and reported by a health plan. Provider data that is inaccurate and/or incomplete can have a significant impact on any of the following: 

• Place a member’s care at risk or limit a member’s ability to access care that is appropriate and timely.
• Increase out-of-network care and costs to members and your organization.
• Decrease an organization’s ability to deliver care efficiently and improve outcomes.
• Increase administrative and overhead costs associated with correcting errors in provider data.
• Impact an organization’s ability to mitigate risk, detect fraud, and meet regulatory requirements.

Quality of provider data can impact core business functions such as claims processing, referrals, credentialing, provider directory, network management, compliance, complaints and appeals, program integrity, and information exchange with stakeholders.

Striving toward improving the quality of provider data not only influences the member experience, it also affects business relationships with providers and employees. Let’s examine some key areas that are affected by poor provider-data quality. 

Striving toward improving member data

1. Member Experience

When the data in a plan’s provider directory is inaccurate or out of date, members can have a poor experience at the very beginning of their care journey. Let’s take one real-life example: A mother goes to her plan’s provider directory to find a doctor for her 9-year-old. She calls two family practitioners on the list but finds that both no longer participate in her health plan. A third practitioner on the list does participate in the plan but is not accepting new patients.

The parent finally gets an appointment with a fourth practitioner — six weeks out. The member and her child arrive for the appointment but are turned away because the doctor only sees adolescent children (12 years and older). The provider directory notes the doctor sees children but does not indicate specific age ranges the provider treats. This results in a delay of care, and the parent must start the process over.

Now, imagine that that member gets a call to evaluate their experience with the health plan. We can assume the satisfaction scores for this member will be low. If the problem is widespread, there could be a potentially adverse effect on CAHPS scores, which is one of the major components in health-plan ratings. Other considerations include word-of-mouth about inaccurate provider directories spreading and the reputation of the health plan taking a hit.

Another member-oriented problem centers on identifying practitioners as in-network or out-of-network. A member may receive bills for services because they saw an out-of-network provider even though the directory indicated the provider was in-network. Who pays the additional cost? The member may be responsible for the balance. The member must try to resolve the issue, which can be time-consuming and stressful. Worse, collection notices may be sent to members.

In one study, the Centers for Medicare & Medicaid Services (CMS) found that 45.1% of provider-directory locations listed on online directories were inaccurate. There are multiple reasons for the inaccuracies, which can be corrected with a Provider Data Quality program.

2. Provider-data accuracy

Providers who are not paid accurately can result in lower HEDIS scores — and by extension, lower reimbursement to a provider group. This can create an atmosphere of mistrust between the plan and the provider. If that’s a pattern, it’s possible that a provider may be less likely to maintain their contract with the plan. Incorrect claims payments due to wrong or incomplete provider data may also result in increased administrative and overhead costs related to work needed to reprocess the incorrect claims.

Incorrect provider address can also have a negative impact. If a provider’s address is incorrect, payment may be delayed. At a minimum, the result can be increased provider abrasion, but there’re also potential fines for missed or late provider payments — not to mention filing complaints or lawsuits against the health plan.

3. Accreditation and government contracts

Incorrect provider data that results in numerous incorrect or delayed claims payments or which hinders a member’s access to care can result in the loss of a health plan’s accreditation or contract with government programs (i.e., Medicare, Medicaid).

4. Business process

Trying to mitigate the problems encountered above takes valuable time away from health plans that could be spent improving care delivery and customer service. Tying up staff to deal with problems that could be prevented is not cost-effective.

5. Finance

Just like any other business, health plans rely on their financial bottom line. If payments are not timely or accurate, the financial picture is inaccurate. Health plans are required to have reserves to assure regulators that they are solvent. Issues regarding providers’ payments put them at risk.

6.  Employees

Incorrect provider data also creates an adverse effect on the morale of a health plan’s employee base when staff must interact with displeased members or unhappy providers or work longer or extra hours to handle a claims backlog that’s caused by poor provider data. Employee turnover is costly. Moreover, health-plan complaints from providers and members are metrics tracked by state and other regulatory agencies.

Sources of inaccuracies which a healthcare consultant can help fix

A healthcare consultant can work to improve several areas where data needs to be improved. Why and how can data be so inaccurate? There can be gaps due to providers working in multiple locations, variable sources of provider data, and instances of inputs within data fields not matching.

• Multiple locations: Providers work in multiple locations, making analysis by provider groups difficult. Provider sites may not send timely rosters to a health plan, so additions or deletions from a directory also become inaccurate. Untimely or incorrect rosters can undermine a plan’s contract with provider organizations in terms of meeting regulatory standards. If a high-performing HEDIS provider is attributed to the wrong practice group, value-based payments to the provider may be reduced.
• Multiple sources: Provider data comes to a plan from a variety of sources, including provider-health plan contracts, credentialing records, and state files. The information from these sources is all too often out of sync. Determining the source of truth can be difficult and time consuming.
• Multiple data fields: Because there are many variables that help inform provider entries, there can be conflicting information about specialties; types of patients (age, pediatric, geriatric); open or closed rosters; the lines of business in which the provider participates (Medicaid, Medicare, Commercial, HIX, etc.); and more. 

Also, provider credentialing occurs every three years. Health plans need to verify credentialing to place the provider or group practice in their directory and remain in compliance with regulatory bodies. Poor provider data can make keeping credential files up to date complicated or delayed. Changes to provider information must be distributed to all areas that use provider data.

Accurate and up-to-date provider data is important for ensuing alignment between the member, provider, and health plan. In the end, high-quality provider data can help your health plan succeed and potentially avoid preventable, costly problems, including member abrasion, costs related to re-adjudication of claims, provider shortages, financial instability, and employee turnover. Let Change Healthcare Consulting help your organization save money, reduce waste, increase productivity, streamline data, and improve your overall provider and member services. Our consultants have 20 years of experience in system implementations, business and data analysis, data architecture, data quality, data migration, and data governance.

For more information about reaping financial rewards due to improved provider-data quality, visit the Change Healthcare Analytics and Insights Consulting site. You can also read about a case of Change Healthcare Provider Data Remediation.