- Providers and their payers oftentimes have a love-hate relationship. Payers boost the number of patients walking through physician office doors using provider directories as well as reimburse providers for treating those patients.
But navigating how to join a plan’s network just to see those patients and get paid for providing healthcare services involves extensive communication between the stakeholders and substantial administrative work.
That communication and administrative work is likely to increase as the federal government shines a new spotlight on provider directory accuracy.
Provider directories are lists of providers and services available to beneficiaries enrolled in a health plan. Payers design provider directories to help their beneficiaries find high-quality, in-network providers.
Yet, CMS recently found that provider directories for Medicare Advantage plans were significantly inaccurate. The review of 54 Medicare Advantage Organizations revealed that 45 percent of the provider directories contained inaccuracies, such as the provider not being located at the directory’s address, incorrect phone numbers, and erroneous information on whether providers were accepting new patients.
In light of significant data integrity issues, CMS intends to review one-third of all Medicare Advantage Organizations each year to ensure provider directory accuracy. Payers may also face directory audits even more frequently if “triggering events” occur, like a provider joining their network.
Consequently, providers may find that their contracted payers are searching for provider data more often under new rules.
But many health plans are not technologically advanced enough to facilitate better data sharing and integrity with their providers, especially when it comes to establishing accurate provider directories, explained Deloitte Consulting LLP experts at the AHIP National Conference on Medicare.
“The challenge around directories is a multi-faceted issue,” Bobby Vaitla, a Senior Manager at Deloitte, recently told RevCycleIntelligence.com. “It isn’t something that happened because we have the wrong data on the website. It goes back to how we are managing the provider.”
Provider data is at the center of a range of payer responsibilities, from claims reimbursement, membership, and provider directories to performance measurement, quality reporting, and customer relationship management.
Despite staff from across the payer organization using the same provider data, each department views their data integrity and sharing problems separately.
“Everyone tries to get to the problem individually and that exacerbates the whole situation,” he stated. “But at the end of the day, it’s the same data that everybody uses and it should be looked at as one problem to solve and then, to submit it out to everyone else to use.”
“Our challenge is trying to get our organizations to manage the provider as a whole across a provider ecosystem and not in piecemeal,” he added.
Provider data is also difficult to manage because the information is constantly changing. Practice locations move, providers take on multiple roles at different organizations, and phone numbers change.
To keep provider data correct, payers traditionally use an outreach method, stated Lucia Guidice, Managing Director and Government Programs Practice Leader at Deloitte. The outreach approach includes phone calls, newsletters, emails, and some self-service tools in which providers can manage their own data on payer systems.
Phone calls are the staple of payer outreach initiatives, Vaitla added. However, when a provider experiences a change, such as moving to a new address, every health plan he contracts with is calling him to update their information.
“If I’m a provider, it’s not high on my list to proactively make that change and have multiple phone calls come in from my health plans,” he said. “It’s not efficient and it makes me frustrated. There’s got to be a way to fix that. It’s public information.”
Not only are providers frustrated by the traditional outreach method, but payers are eating away at their administrative budgets. Payers may end up hiring 20 individuals just to make phone calls or send emails to providers to update their data.
Even when payer representatives catch a provider data integrity issue, challenges still persist. With departments working in siloes, an update to a provider’s information may not reach other departments in a timely manner, if at all.
How do you keep track of changing information from providers across your network when data governance does not exist, asked Vaitla.
Each payer department aims to increase the accuracy of their provider data. But when a single entity does not own the information, changes to provider data may not be shared within the organization, resulting in another department using outdated data for other duties, such as claims reimbursement or provider directory updates.
“You have to look at it holistically,” he advised. “Try to nail down exactly the golden record of what my information is going to be and who is going to be using it. Almost make it like ‘Mother May I,’ where if you need something, let me know and I’ll give it to you because I own the information.”
Innovating a new way to collect provider data
Providers should expect payers to approach them in a new way to collect accurate, robust data for provider directories. But they may not see the actual innovative method come for some time.
Right now, the innovators are payers who are acknowledging that improving provider directory accuracy isn’t necessarily just a provider directory problem. Innovative payers are currently the ones who are saying that it is a provider data management issue, explained Giudice.
Advancing the way providers and payers communicate to share data will involve an organizational, mind shift change, elaborated Vaitla. Part of that organizational change will be for payers to enrich their data sources, rather than relying on outreach methods that add administrative burdens on their organization and providers.
“Data enriching the information you have from other sources helps a lot. It reduces the reliance on outreach,” he explained.
Sources, like practice or organization websites and provider credentialing, can help payers to complete provider data sets.
“Provider information is still, for the most part, public information and we shouldn’t be managing differently from plan to plan to plan,” he continued. “There’s got to be a more seamless way, whether it’s technology-driven or process-driven or whatever that solution is.”
Innovative payers are also turning to their own data to glean insights into their providers, Giudice stated.
“The other thing we are hearing from plans is that they are trying to use their own data and analytics to guide them where there might be problems in the data,” she said. “Like, if a provider hasn’t had a claim in a year, well that provider is probably not in the network anymore or not practicing.”
By analyzing data already within their systems, payers can better target outreach solutions to reduce the administrative work being performed.
“With most health plan problems, we are often talking about how do you use data to target what you are doing so you’re not outreaching to everybody,” she elaborated. “You are trying to figure out which providers are the most likely to have data problems and you’re going to focus there because no plan has unlimited administrative dollars.”
The more proactive a payer can be using data analytics, the fewer problems the organizations and their providers will face with claims reimbursement processes, Vaitla added.
“For example, you may have a provider and a contract,” he elaborated. “It takes some time to get to the claims system, so you’re probably still paying claims to a provider and then you have to try and clawback the money.”
With the next generation of provider data collection and analytics, data integrity will be automatic and streamline data sharing, he continued.
“With the next generation we are talking about, if it turns off, it turns off. It’s instantaneous,” he said. “You’re not worrying about segregation and clawback and all those things can go away automatically.”
Value-based contracting shines a light on better provider data management
CMS is spurring payers and providers to improve provider data management and integrity to increase the accuracy of provider directories. But provider data management will become even more important to both stakeholders as they increasingly engage in value-based contracting.
Claims reimbursement attribution is a staple of value-based contracting. During an episode of care, multiple providers may treat a patient and contribute to the episode’s patient and cost outcomes. But how can plans find who should receive payment for that episode?
Provider data is key to finding that information and paying providers accordingly.
“It’s about attribution from a certain standpoint,” said Vaitla. “How do you allocate a certain part of the claim payment for services rendered to a certain provider if the patient has seen two doctors in the same practice or multiple practices? How do you measure performance for that particular episode of care?”
Provider data is also crucial to accurate provider performance measurement in value-based contracts, Guidice added.
“If you’re going to put providers at risk, you need to understand how they are performing against goals you set for them,” she said. “If your data isn’t good, you’re not going to be able to pinpoint who the high-performing efficient providers are, who should get recognized monetarily for that and who shouldn’t.”
Providers may also find that their performance under value-based contracts influences whether they are in or out of a payer’s network. As payers use provider data to track performance and outcomes, plan leaders can identify their cost-efficient providers and narrow their networks to only include high-value providers.
“Then, also thinking of who you want in your network and trimming down your network,” she stated. “It’s all about understanding the performance of the provider. It’s more than just who is in and who is out.”
As value-based purchasing starts to become the norm in healthcare, payers and providers are experiencing a fundamental shift in how they share and manage data. Provider data is not only critical for ensuring directories are correct and beneficiaries can access care, but value-based purchasing relies on provider data to measure and advance quality and cost performance.
Using a streamlined, proactive approach for provider data management will require data analytics tool as well as increased communication between providers and health plans on data governance. But providers should see that information helping to attract customers and ensure timely, accurate reimbursement.