Provider Data Challenges for Health Plans

By Charlie Falcone

While leaving her house to visit her grandson, Sue falls and twists her knee. At the emergency room, the doctors begin a series of tests to discover what’s wrong with her knee. Unfortunately, Sue’s knee injury is complex. It will take months for her to recover, and as she does, Sue will visit multiple clinics and doctors.

Not only does Sue suffer the stress of pain and incapacity, but she also begins to feel like she needs a secretary to manage all of her appointments and bills. From the emergency room physician to the primary care physician to the X-ray technician to the physical therapist to the orthopedic surgeon, Sue gets bounced around more than her grandson’s rubber ball.

Each time she visits a new specialist, she encounters some challenges. When she’s referred to a physical therapy clinic, her referring physician gives her an old address for the clinic so she misses her first appointment and must reschedule. Her X-ray technician tries to send her results to her primary care physician, but because the primary care physician just recently set up his practice, the technician can’t find the current contact information. Sue doesn’t find out her surgeon is out of her network until she arrives at her appointment. Worst of all, she learns two months later that her primary care physician, who’d suggested she consider surgery, had sanctions against his license in another state and shouldn’t have been practicing medicine in the first place.

Many of Sue’s difficulties could have been avoided with current and correct provider data. Many health plans struggle to maintain correct, complete, and current information about providers in their network with today’s complex health landscape. A recent review found that over half of provider directories contain at least one error. As a result, some patients may not get the treatment they need.

Why Has Provider Data Become So Complex?

Managing provider data is more difficult than it used to be. As recently as 10 or 15 years ago, provider data was much more static. Physicians were small businesses or individuals, and it wasn’t unusual to practice in only one location. As a result, certain critical information didn’t change often. Today, practices consolidate often, physicians practice at multiple locations, and multiple specialties might share the same building information. This has led to an exponential rise in dynamic provider data.

In addition, healthcare data has become more automated and electronic. Directory information with physician’s practice information used to be sent through the mail like an old school phonebook. Today all that information is housed online, with much more information required. For example, patients need more information about networks and costs than they did before. Patients also want to find the best provider to treat their specific condition.

Today’s provider data also includes compliance information to mitigate risk. Information about practitioners’ licenses, including convictions and sanctions, are now common and important elements of provider data. This adds another layer of complexity as many of these data points can also be dynamic.

Health plans themselves add layers of complexity to provider data. Years ago, every physician or facility only had to provide information to one or two plans. Now it’s not unusual for a physician to be affiliated with a dozen or more plans, with each plan requiring different information at different points in time. Hundreds or even thousands of data points could be tracked and updated and monitored for each individual physician.

The U.S. health system lacks what many refer to as a golden record: a singular repository of provider information that can be accessed by stakeholders who need it and have the proper credentials to view and use it. Currently, provider data is collected by multiple sources that each use their own software systems and workflow. Although digital records are more accessible today due to the use of Application Programming Interfaces (APIs), the industry’s current overall lack of transparency and accessibility leads to duplication and fragmentation. We still have a long way to go before seamless data integration becomes a reality.

What Are the Risks of Data Fragmentation?

In the meantime, we still need to use the data that’s available to us. Inside a health plan, health system, or government agency, provider data may be reviewed and evaluated by numerous people who depend on the information to make decisions. Inaccuracies and fragmentation in provider data can cause harmful ripple effects that touch entire organizations. For example, if a health plan overestimates its number of providers due to duplication of records or ineligible providers, it will lead to compliance problems and unhappy members.

Payment integrity is another example of how a seemingly small provider data inaccuracy can create a large financial problem. When a provider submits a claim electronically and it’s processed through auto-adjudication, certain rates are automatically assigned to services. This of course allows providers to be reimbursed faster for their services. If the provider data is incorrect, incomplete, or out-of-date, it disrupts the process, and the claim must be adjudicated manually. This creates exceptions, necessitates manual workarounds, and may cause other technical issues, which all takes extra time and drives up costs.

For patients, the consequences of inaccurate provider data can be more serious. Patients and their caregivers need provider data to find doctors to help them with their illnesses, and inaccuracies in provider data can affect patients’ ability to access appropriate care. In patient Sue’s case, the delays were inconvenient and frustrating. In the case of a patient with a more serious illness or injury, delays can be life-threatening.

How Does the No Surprises Act Improve Provider Data?

The No Surprises Act (part of the Consolidated Appropriations Act of 2021) requires a higher standard of provider data transparency from health plans to ease delays and unexpected expenses. Starting in January 2022, health plans were required to verify and update provider directory information within 48 hours of a change in provider information, such as a new health plan affiliation or new address. If the information is not updated, any associated costs from that error are passed on to the providers.

This legislation has created necessity and urgency around maintaining accurate and complete provider data. For physicians participating in multiple health plans, constant requests for data can necessitate hiring a full-time staff to keep up with the ongoing administrative burden. Health plans scramble to get the information they need in real-time. Providers and health plans alike are looking for data solutions that will help them stay current and compliant.

Despite these challenges, having provider data and provider directories that are accurate and up to date is possible. With the right processes, software, or partnerships in place, health plans can solve common provider data challenges.

To learn more about our provider data management solutions, contact a member of the Verisys team today.

Charlie Falcone is a senior leader with more than 25 years of management and operational experience in healthcare. He’s passionate about the need for greater consistency and compliance in provider and workforce data management. As CEO of Verisys Corporation, he sets the company’s vision, strategy, and growth initiatives.