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Jul 20, 2020

Inaccuracies in Provider Directories: How to Overcome these Challenges for Your Health Plan

How to Overcome these Challenges for Your Health Plan

In a world where accurate information is available in real-time, patients have similar expectations with their Health Plans for provider data information. Finding a doctor only to discover that they do not practice at a location mentioned in the Plan directory is a frustrating experience, not to mention the potential out-of-pocket costs resulting from an out-of-network provider encounter. Health plans need to be diligent in maintaining their provider data accuracy and invest in the technologies and resources required to meet consumers’ expectations.

Reasons Why Directories Fail to Provide Accurate Information

Ensuring that members have access to up-to-date provider data is important to streamline access to care and maintain member satisfaction. However, health plans repeatedly find inaccuracies within their directories. Federal and state policymakers have put in place regulatory requirements for health plans to keep their data updated. But, full compliance is often hard to achieve.

Here’s the problem—health plans and providers do not share the commitment to resolve the issue of maintaining provider directory data. In the absence of sufficient administrative bandwidth, providers cannot keep up, and inaccuracies become inevitable.

Common Drivers of Deficiencies in Provider Directories

According to this report by The Centers for Medicare & Medicaid Services (CMS), here are the common reasons why provider directories often fail to contain the right information:

  1. Group-level reporting rather than provider-level reporting. Group practices can have multiple locations, and some providers may only participate at certain locations. The lack of this level of accuracy is frustrating to consumers.
  2. Lack of resources and suitable processes. Health plans do not have the time and resources to routinely audit and test the accuracy of their data.
  3. Lack of provider responsibility. The assumption that providers will inform of any changes as they occur leads to inaccurate information left untouched for years in provider directories.

Implications of Inaccurate Provider Directories

Inaccurate provider directories result in a major cause of frustration for the plan members, for providers, and for health plans.

Key Repercussions of Inaccurate Directory Information

  • Increased plan member frustration in locating a provider. Trying to contact a provider only to find they don’t have the specialty or the doctor in question is not there anymore is very frustrating for patients.
  • Decreased access to care by the plan enrollee. When they cannot locate the right provider, the beneficiary loses valuable time when they could have been treated.
  • Directory inaccuracy calls into question the plan’s ability to meet the beneficiaries’ health care needs. Thus, they may opt for different plan options during re-enrollment.
  • Increased Administrative Costs for health plans. Inability to contact a provider and make an appointment leads to increased calls and complaints to health plans’ customer service lines.
  • Compliance Issues. In case of CMS audit, health plans may face penalties if the directories are not compliant.
  • Insurance coverage issues with providers. According to this survey, every month more than half of US physicians encounter patients with insurance coverage issues due to inaccurate directories resulting in additional administrative time.

Retain Member Participation, Reduce Admin Costs, and Eliminate Compliance Issues With PRIME

PRIME’s technology relies on continuous data aggregation, enrichment, and analytics through an integrated platform to deliver the most comprehensive, current, and accurate provider data at a reduced total cost of ownership. Our market-defining data validation solution seamlessly integrates with existing Provider Data Management Systems to provide accuracy levels of up to 98%.

PRIME delivers more value to you by:

  • Providing flexible options for outreach and validation. This includes direct call outreach, self-service, emails, faxes, and mail. You can count on over 95% validation data quality with 100% outreach completion.
  • Offering the assurance of data integrity We remove duplicates, normalize, and geo-code the information before we validate.
  • Offering access to pre-validated provider data.  Health plans can use pre-validated network information to gain immediate access to validated provider data, hence eliminating all outreach overheads
  • Reducing your risk of member complaints and potential penalties. Timely and consistent completion of campaign outreach ensures that the directories are accurate, which in turn ensures member satisfaction.
  • Being better prepared with our CMS mock audit to identify data weaknesses and potential compliance violations. We provide access to all outreach attempts and artifacts such as phone recordings, communications, and change history for each modification.
  • Check off accessibility guidelines with our CMS-mandated print-ready provider directories. With PRIME’s standard as well as accessibility directories, you can provide equal access to all users.  

PRIME Hub goes straight to the source to correct errors and bring information into alignment. Use our team to alleviate the additional resources channeled into provider directory management and follow-ups. You can depend on us to keep your data as up to date as possible.

Contact us today to learn more about how PRIME Hub’s provider data validation and compliance solutions help you achieve and maintain accurate provider directories.

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