Availity Blog

Why health plans need better provider engagement to improve provider directories.


4.25.2018 By Mark Martin, Director, Payer Solutions - Provider Data Management


CMS’s recent report on the state of provider directories identified three challenges facing health plans. Recent blogs covered the first two challenges: the issue of contractual versus resource constraints and the lack of internal audits by health plans to verify provider information. A third problem creating directory inaccuracies is that health plans rely on providers to reach out and tell them when information changes. From the report: “MAOs cannot assume that they will be informed when a change in provider location occurs; instead, MAOs need to implement routine processes that drive more accurate information reflected in their directories.”

It’s true that health plans need better processes to capture data from providers, but it’s more difficult than many realize. Here are a few reasons why.

Over-reliance on static data

Health plan-provider annual contracts and recurring credentialing events are historically the main sources of data for provider directories. This means that even if a directory were 100 percent accurate when published (which is rare), it wouldn’t remain up to date for long. Provider location information—like phone numbers, office hours, and whether a physician is accepting new patients—changes throughout the year, so health plans need a way to capture these updates when they happen, rather than wait for the contract or credentialing cycle to refresh. Additionally, data provided for contract or credentialing events does not necessarily match the context of how it might be used to update a directory listing. Read more about clarifying context when asking for information in part two of this blog series.

Time-consuming, manual processes

CMS notes that health plans need to proactively reach out to providers for updates, and many plans do that today by sending forms for providers to complete and return. However, this is a lot of paperwork for short-staffed provider offices to manage, especially when each plan has its own unique form and submission process. For providers, completing these forms is a lower-value activity when compared with seeing patients or submitting claims, so if health plans want to get the most up-to-date information, they need to make it easier for providers to do so.

Lack of provider incentives

Health plans and providers must work together to help ensure provider data stays up to date, but ultimately health plans are solely accountable for the quality of their directories. Without a Federal or state mandate for providers, health plans should focus on developing incentives and educating providers on how maintaining accurate data helps them, including reducing denials and improving patient outcomes by ensuring patients can access care when and where they need it. We’ve highlighted five reasons provider data is important to providers in an earlier blog.

Why Availity

Availity’s Provider Data Management solution is one of the few provider directory applications that acknowledges the challenge of capturing accurate data from the providers without placing an onerous burden on them. Providers are notified in their workflow about data discrepancies, and can then digitally update the information and attest to it. These updates are then made available to all the participating health plans the providers work with, rather than the provider having to complete multiple versions of forms requesting essentially the same information.

Want to learn more? Visit Provider Data Management.


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