CMS Provider Data
Part One: Group and provider-level data

In its second annual report on the state of provider directories, the Centers for Medicare and Medicaid Services (CMS) found that 46 percent of all directory entries reviewed contained at least one error that makes it difficult for patients to find doctors in their networks.

In the report CMS identified three drivers of directory deficiencies: group vs. provider-level data, lack of internal audits, and reliance on provider-led notifications. I’ll be covering each problem in detail, but in this article I want to expand on why there are often discrepancies between group-level and provider-level information in provider directories.

Contractual versus Resource Constraints
To understand why health plans struggle to maintain accurate provider directories, it’s important to recognize there are two, sometimes competing forces at play: the contractual agreement with provider groups and the regulatory requirements around network adequacy. Health plans contract with provider groups to increase the size and reach of their network, so if the group has five locations with 25 physicians, it makes sense for the contract to cover all physicians at all locations, even if all physicians don’t practice at all locations.

Provider groups also have an incentive to list all providers in all locations in the contract. They want to ensure claims are paid, regardless of which location the patient was seen at. For example, Dr. Smith only sees patients at the Westside location, but her colleague at the Eastside location is on vacation so she is covering for him for two weeks. Dr. Smith is contracted at the Eastside location, but she is not actively taking appointments there. However, the provider directory lists her at all of the group locations because much of the data is pulled from the contract. To get Dr. Smith’s true availability, her office must be contacted directly.

Here’s where the conflict between contracting and regulatory compliance comes in. When evaluating network adequacy, CMS and other regulating agencies verify the directory’s accuracy not by looking at the contract but by contacting the individual providers or locations, just as a patient would.

Fixing provider data starts by building trust
A barrier to fixing this issue is that health plans and providers both have incentives to maintain the status quo as it relates to contracting. Health plans want to demonstrate robust network coverage and providers don’t want to risk denied claims. The problem of inaccurate provider data can’t fully be addressed until both health plans and providers address the underlying trust issues that stand in the way of transparency.

It won’t be easy, but Availity is committed to helping improve collaboration between health plans and providers. Learn more about our efforts with provider data management or read up on why provider data is such an important topic in U.S. healthcare.