As the volume and variety of health insurance products increase to accommodate an expanding market, so do concerns about the accuracy of provider network information. Data quality is a significant issue for health insurers, as evidenced by the recent fines of more than a half-million dollars against two large insurers because of provider directory errors. To mitigate risk, health plans need to improve their provider data management.
Consumers rely on provider directories to verify if a preferred doctor is in-network. If the directory is incorrect, they may be charged higher, out-of-network rates. In addition to member dissatisfaction, these inaccuracies also put health plans at greater risk of litigation, government penalties and investigations, and significant administrative costs associated with correcting errors.
In response to consumer concerns about data quality, federal and state regulators have added more specificity around what constitutes an adequate provider directory. It must include an accurate listing of participating facilities and physicians, along with information about their location, specialty, hospital affiliation, and languages spoken. Health insurers must also have both hardcopy and online versions available, the latter accessible from the website.
As health plans try to adhere to these regulations, they face tremendous operational challenges. Many health plans still rely on manual data gathering processes, which isn’t practical given the high volume of data and the rate of change. Health plans need to consider ways to automate these processes to improve the accuracy and currency of the data.
In cooperation with Availity and America’s Health Insurance Plans (AHIP), Brian Hoyt, Managing Director of Berkely Research Group, will present a webinar on Dec. 1 at 1:00 pm ET that will use the CMS guidance concerning provider directories as a launch point, then walk health plans through the data elements most critical to effective provider data management. With the fundamentals covered, the webinar will move into higher-level uses of provider data, with an emphasis on planning to avoid the risks and liabilities that can result from poor data management.
Download the webinar slide deck
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