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Provider Data Standardization Critical to Improving Inaccuracies

A CAQH group advised stakeholders to commit to provider data standardization by defining fundamental data elements and developing a centralization solution.

Provider data standardization and accuracy

Source: Thinkstock

By Jacqueline LaPointe

- A multi-disciplinary workgroup is calling for provider data standardization to ensure accurate provider information is available for connecting patients with providers, licensing providers, and paying for services.

The Provider Data Action Alliance, convened by CAQH, recently highlighted the challenges of provider data collection, submission, and accuracy, and put forth a roadmap for improving the data submitted to payers. 

“Inaccurate provider data has long been a significant challenge for healthcare,” said CAQH Executive Director Robin Thomashauer. “Individual providers, provider organizations, patients and health plans are all affected by this issue, and it requires a collaborative effort to achieve real change.”

Maintaining provider data is a $2 billion operation for the healthcare industry. Yet, inaccuracies and inefficiencies are still a major issue.

Over one-half of physicians in a recent American Medical Association (AMA) and LexisNexis Risk Solutions survey said their patients faced coverage issues at least once a month because of data inaccuracies in provider directories. Patients were unable to access accurate information on practice address, contact numbers, network designations, and new patient acceptance.

READ MORE: Provider Data Integrity Key to Directory Accuracy, Value-Based Care

A recent CMS audit of Medicare Advantage plan directories also revealed that 52 percent of practice locations listed had at least one inaccuracy, and provider directory inaccuracies with the greatest likelihood of interfering with care access were found in almost 46 percent of all locations.

A lack of authoritative data sources and provider data standards are driving these directory issues, the Provider Data Action Alliance found.

Few aggregators of provider data exist that can authoritatively gather data elements and create complete provider data records, the Alliance explained. And for many data elements, no accurate sources exist for stakeholders to use, creating data compatibility challenges.

In addition, multiple sources may be deemed authoritative for the same data element, leading to confusion and potential conflicts.

Adding to the provider data issue is the fact that payers have different provider data standards and requirements, the Alliance added. Payers use different reporting formats and the industry has not adopted a single standard transaction type or application program interface (API).

READ MORE: Type of Provider Data Presented Influences Patient Volume, Choice

Providers also tend to be unaware, or misinformed about, how their data is used by payers. For example, providers may submit practice locations for provider directories that are accurate for medical billing purposes but not for patient access.

“Variations in the format, exchange, content and understanding of the uses of provider data represent an unnecessary cost to the healthcare system and an obstacle for patients and other users of data who need access to reliable provider information,” the group wrote. “As a result, provider data is communicated inefficiently, causing attrition during transmission and encouraging data users to source data directly rather than decipher inconsistent datasets that have been sourced by others.”

To resolve provider data challenges, the Alliance recommended that the industry start declaring a commitment to improving provider data and creating a non-profit governance model to lead improvements.

“To achieve the widespread adoption of provider data solutions, stakeholders from across the industry must be involved and committed, with strong participation from the provider community,” the group explained.

The non-profit advisory board who oversees provider data improvement governance should be responsible for:

READ MORE: Maximizing Provider Revenue with Payer Contract Management

  • Establishing and maintaining technical and business standards
  • Developing guidance and direction on the infrastructure needed to drive progress
  • Informing new strategies for provider understanding, engagement, and stewardship
  • Evaluating and encouraging provider data improvements

The advisory board and industry stakeholders should also define a subset of fundamental data elements, the Alliance suggested. The elements should include unique identifiers for providers, groups, and locations.

The fundamental elements should also define data points that are particularly difficult to match or compare and come from existing data sources, if possible.

Stakeholders should then develop a standardized record format to aid provider data exchange and reduce data discrepancies.

To aid provider data standardization, the Alliance also urged stakeholders to create a centralized solution that collects fundamental data elements from different authoritative systems. The centralized authoritative database should:

  • Aggregate sources of truth for fundamental provider data elements, including the National Plan and Provider Enumeration System (NPPES)
  • Implement best practices for provider data accuracy
  • Include a portal into the fundamental dataset that allows producers, maintainers, and users of provider data to update and fix data for which they are responsible
  • Use an acknowledgment system to inform data producers about where the data is going, how it is used, where errors are introduced, and when a data update has reached its target

“This centralized solution should support data exchange with other nodes, including regional solutions or other partial solutions that may be authoritative for select data elements,” the group added.

Standardizing provider data and developing the infrastructure to support the information is a monumental task, but the Alliance emphasized that the industry can achieve these goals by formally committing to provider data improvement and creating a non-profit multi-stakeholder group to lead the efforts.

This group will lead an incremental approach to establishing provider data standards, technology standards, common operating rules, data quality standards, and technological infrastructure. The group will also be responsible for ensuring distribution of and adherence to provider data standards, as well as measuring the industry’s progress with the provider data improvement.

“Through the development of this Roadmap, the Alliance and its participants agreed that the industry must chart a new path toward a more accurate and efficient provider data ecosystem,” the CAQH group concluded. “The pressing needs of stakeholders require that momentum be developed quickly, while ensuring a holistic, measured and methodical approach.”


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