Committing to Accurate Provider Directories

Each year, provider directories are used by millions of Americans to find in-network doctors or to find a health plan in which their current physician participates. For consumers to make informed decisions, it’s up to insurers and their provider partners to ensure that the directories are both accurate and up to date.

Uncovering Solutions

Last year, Availity, the nation’s largest real-time health information network, participated in a pilot initiative with America's Health Insurance Plans (AHIP) to identify solutions for providing real-time updates and validation of provider directories through a single workflow.

The pilot was conducted in three states and with the participation of more than a dozen health plans. Availity’s participation involved five Florida insurance carriers, which partner with more than 20,000 practices and provider organizations and 100,000 physicians across the state.

Availity guided providers to a directory validation form through an online portal. Providers received a notification on a system that they already use for other important tasks with the health plans. By catching providers within their existing workflow, validation was done much more quickly and effectively—more than 786,000 unique corrections to data were made by providers during the pilot.

Availity’s solution creates a profile of every physician in the company’s network of more than 900,000 active providers, and alerts providers to “check and correct” their information in a provider’s existing workflow when Availity identifies anomalies. Using a simplified user interface, providers can easily validate their profile or make critical updates, such as new office locations, office hours, physicians, and care specialties.

What makes Availity’s PDM solution different is that we are not using other-sourced information, like information drawn from electronic health records or data purchased from third-parties. We are getting our information directly from the providers, validating it against our trusted provider directory, and confirming it through a closed loop interaction in the workflow.

Strategies for Success

The financial risks of not addressing provider data accuracy are becoming too big for Health Plans to ignore. To that end, the plans have an opportunity to recalibrate how provider data is collected, stored, and updated. The AHIP pilot concluded that health plans should assess and implement notification strategies that work best for connecting with their provider networks. Strategies Availity recommends include:

Provider System Audits. Conduct an audit of legacy systems and entrenched processes to gain insight into where there are redundancies and deliver a roadmap for what can be consolidated.

Reconsider Required Data Elements. Is it more important to get all the data at the expense of clean data? If health plans can address state and federal mandates using a core set of data elements, they can streamline the process for providers.

Incentivize Providers. Health plans currently bear full responsibility for the accuracy of provider directories, and should consider ways to incentivize providers for providing timely updates.For example, health plans have built a variety of online portals and other online tools in an effort to improve communications with providers. However, for providers who work with multiple health plan partners, having to use multiple portals—each with its own design and navigation—can make the process of communicating with the health plans too complicated.

Multi-payer platforms provide a far more user-friendly option, giving providers a single point of entry and streamlined navigation. Best of all, they need only update demographic information one time to have the data sent to all participating health plans. Providers don’t have to manually complete forms, and they don’t have to manipulate their data to accommodate each health plans’ preferred data structure.

By employing the strategic planning and intuitive technology, health plans can meet federal and state mandates while reducing unnecessary abrasion with their provider networks, and provide a better member experience.

Access the AHIP Issue brief on pilot findings here.