Electronic Health Reporter

By Priya Sabharwal, practice leader, network operations, HGS.

Imagine a scenario: A patient looking for a new doctor searches her insurer’s online network directory to find a provider her plan will cover. She selects what seems to be the perfect doctor based on her criteria, which could include gender, office location, languages spoken or other qualifications, in addition to being in-network with her health plan.

But there’s a plot twist: The patient eventually learns the doctor she found is not, in fact, the right option for her – but it took her scheduling and arriving at the appointment for her to realize this. It turned out the entry in her insurer’s directory was outdated, and her doctor had moved offices.

This scenario is hardly out of the ordinary. A 2019 Health and Human Services survey uncovered errors in half of the listings in Medicare plans alone. These significant inaccuracies cause issues not just for patients, but for payers and providers, too:

• Poor directories are more than just an inconvenience for a member; they also impede their access to necessary care, and can create unexpected medical costs.
• A typical health plan is already regularly contacting providers’ offices for many different types of data requests. When they also call to verify provider directory requests, it can create added pain for both sides of the equation. On the payer side, it can create provider abrasion, which could influence whether the provider keeps doing business with that payer. On the provider side, receptionists and office managers are pulled away from their higher-level tasks whenever they stop to answer the phone, leading to short-term frustration and, potentially, burnout.
• Payers risk incurring stiff fines and penalties from federal and financial entities, and/or member lawsuits. For example, as of 2016, CMS regulations now permit the agency to fine health plans up to $25,000 per Medicare beneficiary for errors in Medicare Advantage plan directories, and up to $100 per beneficiary for mistakes in plans sold on the Affordable Care Act exchanges.
• Poor provider data management hinders effective patient-provider matching, patient satisfaction, and demand conversion through call centers.
• If a health plan’s website does not contain thorough, accurate provider information, or reflect correct provider availability, potential patients may go back to the drawing board and select a provider from a different organization.
• A lack of complete and reliable provider data about specialists leads to misdirected referrals, and acts as a barrier to patient retention within networks.

So what are some steps payers and health plans can take to create a solid provider data foundation? It starts with fundamentally changing the way we think about, use, enter and maintain data.

Building a Better Provider Data Foundation

1. Establish a centralized provider directory. Simply having one repository where all data lives and can be updated as needed, and in real time, will eliminate some inconsistencies and redundancies. Any outdated data must be removed.
2. Create a provider engagement program. Each state has its own mandate on how often provider outreach can be done through channels such as phone and email. Health plans should create programs that not only comply with states’ mandates, but also work for the providers — e.g., instead of reaching out multiple times to the same provider to confirm different pieces of information, figure out all the necessary data (whether it’s missing or outdated) and make one single outreach. This minimizes the hassle for the provider while maximizing the information retrieval for the health plan, and also helps to create an understanding of relationships between data.
3. Develop a provider data governance strategy. Data governance has multiple components to it — e.g., ensuring all of the same types of information are entered the same way into a system, protecting master data so there is always a core record to refer to, and developing and using business rules to categorize and tag the same types of data the same way. Policies and procedures must support the relational model.
4. Make provider data accessible to key stakeholders. Provider data comprises multiple facets, and stakeholders like the C-suite or marketing often request information such as how many anesthesiologists joined or left a health system in a given month or year, so they can track trends, reconfigure budget, rejigger hiring processes and so on. Having the most accurate, updated information available and accessible enables a health plan to use it to make informed business decisions.
5. Implement an analytics solution. While having a solid foundation of provider data is an excellent start, healthcare systems can go further by adding an analytics tool that can pull out even more macro- and micro-level insights. Analytics tools have reporting and dashboarding capabilities that allow data to be presented differently for different stakeholders. This is also useful when it comes to complying with regulations; a healthcare organization can simply create a report showing they are in compliance.

These five steps may sound simple on the surface, but, as is often the case, execution can be a challenge — and that’s where it can make sense to turn to a business process outsourcing (BPO) organization.

As specialists in transforming and optimizing processes, BPO organizations can help health systems ensure their provider data is properly managed, accurate and kept up to date, by cost-effectively combining technology, automation, strategy and expertise.

Better Data, Better Member Service

While provider data management has historically been seen as a cost center for a health plan, this mindset is changing in the light of new CMS regulations and a growing focus on improving member experience.

As payers place a higher priority on having a sound, accurate provider data management foundation, partnering with a BPO can bring the latest innovations, deep experience and strategic thinking to the table. This can enable health plans to compete more effectively under current (and ever-changing) market conditions — and, most importantly, provide better service for members.