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Inaccurate Provider Directories Create Barriers to Care

Provider directory management (PDM) can be a significant and expensive administrative burden for health plans and providers. Although the healthcare industry spends nearly $3 billion annually to maintain provider directories, they are notoriously inaccurate.

The Centers for Medicare & Medicaid Services (CMS) indicates that 45% of the average health plan’s provider directories contain at least one inaccuracy. As a result, health plans experience lower auto-adjudication rates and high claims corrections costs—between $8 and $15 per affected claim—not to mention the constant threat of CMS fines and difficulty proving network adequacy to sell in new states.

Additionally, consumers who rely on directories to find in-network services could be sent to unavailable or out of network providers, causing care delays or surprise medical bills.

In response, state and federal regulations mandate that health plans regularly update and attest to their directories. For example:

  • In 2016, California passed SB 137, requiring health plans and providers to maintain accurate directories based on uniform data standards.
  • At the federal level, the No Surprises Act requires health plans to verify and update provider directory information at least every 90 days, including both individual providers and facilities.

Updating directories is easier said than done. A single doctor might network with a dozen or more health plans and be affiliated with a variety of independent physician associations, and hospitals, each with their own health plan contracts.

For providers, this makes directories a constantly moving target—and an incredible source of administrative and financial stress—because each health plan requires different data elements, levels of data granularity, and formats for submission.

The PDM Puzzle

How hard can it be to maintain provider directories? The question assumes that provider data is largely stagnant and should be relatively easy to maintain.

Correcting existing directory information is challenging, but accommodating the three percent of provider data that changes every month makes achieving up-to-date provider directories a moving target. Directory elements, such as service, billing and payment locations, specialties, affiliations and office hours, can change frequently.

Many health plans also continue to rely on legacy systems that store provider data in multiple, disconnected databases. Therefore, to create directories, health plans need to cross-reference their provider data against multiple systems, which means it’s more likely to contain redundancies and incomplete or incorrect data.

As business requirements evolve, organizations have implemented incremental stop-gap measures to address data limitations, but these don’t address the core challenge: the lack of a single source of truth.

The Root Cause of PDM Problems—Data

The root cause of the problem isn’t the directories themselves; it’s the underlying data. Capturing, storing, and retrieving provider data has always been complex.

The transition from fee-for-service to value-based payment models creates a need for better communication and coordination between health plans and their provider networks, particularly around risk sharing and quality measures. To achieve this, health plans and providers need to recalibrate how provider data is collected, stored, and updated.

However, recalibration in and of itself can be a challenge. While health plans recognize the limitations of legacy technology, implementing large-scale initiatives to modernize them requires a significant capital investment, which may not be feasible.

While aggressive multichannel communication- phone calls, faxes, and e-mails- can eventually procure the desired results, it presents other problems. For example, various departments within a given insurance organization are already in regular—perhaps excessive, some physicians may argue–contact with providers’ offices for myriad data requests.

Now add provider directory requests to the mountain of other data requests, multiply it by the number of health plans the average provider contracts with, and you’ve got an acute case of abrasion and no incentive on the part of the provider to be a better collaborator.

A Streamlined Strategy—Availity PDM

Availity Provider Data Management (PDM) is a web-based tool that leverages automation tools and data analytics designed as a single point of entry that supports multiple provider workflows that allows for the provider to enter their data for all Availity participating health plans and for those who are not yet participating with Availity.

Leveraging the extensive reach of the Availity network, Availity PDM compares health plan data with other data sources, such as outside data verification tools and provider-supplied claims data, to achieve optimal provider-matching identification.

Availity PDM makes it easy and convenient for providers to change, update, and/or delete in addition to verifying, certifying, and attesting their data within their portal workflow. When discrepancies or updates surface through direct provider input, claims, or third parties, Availity prompts providers to update and attest to their provider data through Availity’s multi-payer portal.​ Once they make an edit, Availity automatically sends updates to health plans in their preferred format and structure and frequency of updates.

Availity PDM serves as a one-and-done transaction for providers, allowing them to efficiently attest to their information for all participating health plans with one action and providing health plans with the most complete and accurate information possible.

For health plans, Availity PDM’s highly individualized implementation and robust integration empower health plans to:

  • Communicate payer-specific, real-time information to provider networks without the need for multichannel communication, such as phone calls, faxes, and e-mails​;
  • Notify providers in their workflow of data that must be updated​;
  • Receive automated updates every time a provider organization attests​;
  • Utilize an action-tagged consumable data feed that eases consumption and enables automation; and​
  • Maintain compliance with CMS and state-mandated provider directory regulations.  ​

The Choice is Clear

Availity’s PDM helps ensure that health plans have the most up-to-date, accurate information possible through electronic means to avoid the extra time and money cost of manual processes.

Availity’s PDM isn’t just for provider directories, the PDM infrastructure is utilized to call specific information to prepopulate, pre-fill a provider’s credentialing application, provider’s re-credentialing application as well as provider’s enrollment application.

Rather than rely on a patchwork of costly manual processes—phone calls, faxes, and letters—to support provider directory maintenance, health plans can use the strength of Availity’s 2 million provider network to help create and maintain correct and current provider data directory.

Learn more about Availity PDM and Availity Essentials for providers and health plans.

Michelle Barry has served as Availity’s expert on Health Plan Provider Data Management since 2016. Her 30-year career in health IT and information security has focused primarily on healthcare data collection, sharing, and application. Michelle is an industry thought leader in several industry work groups, including WEDI, X12N, HL7 DaVinci, PIE, PDex, Gravity, Patient Care and Gender Harmony.

About Availity 

Availity is the place where healthcare finds the answers needed to shift focus back to patient care. We work to solve communication challenges in healthcare by creating a richer, more transparent exchange of information among health plans, providers, and technology partners. As one of the nation’s largest health information networks, Availity facilitates billions of clinical, administrative, and financial transactions annually. Our suite of dynamic products, built on a powerful, intelligent platform, enables real-time collaboration for success in a competitive, value-based care environment. 

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