Provider Data Accuracy: Navigating the Compliance Landscape

Inaccurate provider data can adversely affect the relationship a Health Plan has with its members and increases the risks of satisfaction while exposing the organizations to regulatory sanctions and potential lawsuits. With poor member experiences and high rates of surprise billings traced to inadequate provider data, relying on provider self-reporting and limited automated validation as mechanisms to maintain data quality are not enough. Your organization needs a comprehensive approach to ensuring provider data accuracy. PRIME offers innovative data validation services that consistently provide 100% direct outreach and over 95% data quality, and helping you meet regulatory and compliance goals.

The Need for Accurate

Provider Data AccuracyNearly half of all provider data is reported as inaccurate, costing Health Plans tens of millions annually in the form of, among other things, mandated reimbursements to affected patients. Health Plans also face federal fines of $25,000 per affected beneficiary for inaccurate provider data. Research also shows that Plans are estimated to spend up to $4 billion per year in attempts to improve provider data accuracy. (Source)

Provider data validation typically relies on various methods including claims-based verification, and external data sources such as NPPES. These have been mostly proven to be marginally effective in helping Plans create a high-quality provider network while ensuring network adequacy. Trends in the regulatory landscape make it imperative for Health Plans to be prepared and have the proper procedures, protocols, and tools in place to ensure provider directory data is accurate.

PRIME for Improved Provider Data Quality

A CMS study found that when Health Plans obtain information directly from the providers, the accuracy of the data improves. PRIME offers a provider data validation solution that works on a direct outreach model and simplifies the complex and time-consuming task of managing and maintaining provider data accuracy.

Our end-to-end processes collect and authenticate the provider data maintained by Health Plans which helps them avoid compliance issues and penalties associated with inaccurate data. We do this by using various outreach channels of communication designed to accommodate a Health Plan’s unique network of providers.

Our provider data accuracy solutions for Health Plans include:

  • Provider validation services that offer superior data quality and results including 100% outreach completion and over 95% validation data quality.
  • Pre-validated provider data that lets you stay updated with instant access to validated provider records.
  • CMS mock audit preparation that gives your organization the results it needs to identify data weaknesses and potential compliance violations.
  • CMS-mandated print-ready provider directories for patients aged 65 years and older. Our accessibility directories provide all users equal access to information and functionality.

PRIME’s technology relies on data analytics and enrichment as well as machine learning to deliver provider data quality at a reduced total cost of ownership when compared to alternative services. Our market-defining data validation solution seamlessly integrates with existing Provider Data Management Systems to provide accuracy levels up to 98%.

If your organization is looking for a way to simplify and improve provider data quality, PRIME’s data validation process offers the high-quality services you need. To learn more about how PRIME healthcare provider data accuracy solutions can help your organization effectively, efficiently, and accurately manage your provider data, contact us today.