Healthcare’s Dilemma with Provider Data Hurts Patients, Progress

By Andy Aroditis, CEO, NextGate
Twitter: @NextGate

Unreliable, contaminated provider data carries with it significant financial, operational and reputational risk. As healthcare swings from a fragmented, fee-for-service model to a highly-coordinated, value-based delivery system, the need for high-quality provider data becomes more critical than ever.

Today’s provider directories remain predominantly siloed, outdated and inaccurate, creating challenges among providers, payers and other organizations for referrals, claims and coordination of care, while causing significant frustrations for patients and plan members trying to locate participating providers in their neighborhood.

Managing provider data—a physician’s name and practice location, clinical specialties, accreditations, accepted insurance plans, whether or not they are taking new patients, office hours and hospital affiliations—is essential for referrals, claims payment, payor contracting, administrative efficiencies and patient satisfaction.

Financially speaking, hospitals, physicians and health plans collectively spend more than $2 billion annually to maintain the integrity of their provider data. Inaccurate provider information leads to financial penalties, lost revenue, delayed reimbursement and denied claims.

In response, federal and state regulators have updated regulations and even increased penalties for health plans with data inaccuracies. The increased focus and potential costs are forcing our healthcare system to rethink how to manage provider directories.

Why is Provider Data so Difficult to Manage?
Provider data is constantly changing and as a result, demands around the clock attention to ensure information is accurate and up to date. According to a 2016 IDC Health Insights report, 2 percent of provider demographics change every month and an estimated 20 to 30 percent of physicians change their affiliations each year. Additionally, 5 percent of doctors undergo modifications in their status annually—retire, lose licenses, pass away or are sanctioned.

Other underlying issues contributing to the persistence of provide data inaccuracies include limited authoritative sources, variation of requirements and standards, and lack of provider engagement. Further, as health systems merge and acquire more physicians, organizations lose control of their provider network.

Implications for Patients
Patients suffer when provider data is disjointed, outdated, inaccurate or incomplete, especially when attempting to select doctors covered under their insurance or when their primary care physician refers a doctor out of network because he or she doesn’t have the most recent in-network data. This can lead to surprise bills and missed opportunities for quality care.

A 2018 CMS audit of Medicare Advantage plan directories found that 52 percent of the provider directory locations listed had at least one inaccuracy, such as the provider not at the location listed, an incorrect phone number, or the provider not accepting new patients when the directory stated that they were.

For patients, these inaccuracies pose as a significant barrier to accessible care. According to CMS, inaccuracies with the highest likelihood of preventing access to care were found in nearly 46 percent of all locations.

Another study by the American Medical Association (AMA) found more than half of U.S. physicians encountered patients with health insurance coverage issues on a monthly basis due to inaccurate directories of in-network physicians.

How the Right Technology Can Help
Employing a centralized, enterprise-grade provider registry that aggregates data across and within subscribing systems in real time or in batch, is one of the best ways payer and provider organizations can address the provider data management problem. This ensures the network’s provider data is continually updated, maintained and shared dependably. Additionally, enterprise platforms are able to pull information from CMS, Medicaid Provider Enrollment, credentialing databases, financial and other third-party reference systems, as well as an organization’s internal sources of physician data, such as admitting, attending, referring and residents, to create a consolidated view of provider information.

An enterprise provider data management platform gives health plans, hospitals and other healthcare agencies a single point of entry and automatically synchronizes and reconciles both individual and organizational provider data, including a physician’s specialties, office locations, hospital affiliations, languages spoken, practice hours, and accountable care organization (ACO) participation. The platform allows organizations to update demographic information just once and have the data sent downstream to participating systems.

With the added benefit of location intelligence, an enterprise provider registry can also identify precisely where physicians offer their services as well as leverage the address of the patient to pinpoint which providers within a specific radius are covered under their plan. Using address verification and geocoding to standardize and authenticate address information in real-time, the Registry’s location intelligence technology delivers extraordinary value to providers, the organizations managing those providers, health plans, and patients enrolled in those plans.

The results? Accurate, up-to-date provider data; improved billing and revenue cycle management; reduced administrative burdens; and a positive patient experience.