Availity Blog

Availity Blog

Actionable insights for medical business professionals

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.”

The second problem CMS identified in its report on provider directories was a lack of internal audits by health plans to verify provider information. The report faulted health plans for outsourcing the audit process, stating “Medicare Advantage Organizations (MAOs) placed full faith in credentialing services and vendor support, and even in provider responses...” and “if MAOs had implemented routine oversight of their processes for data validation, errors in the provider directory would have become apparent.”

The RISE conference in Nashville was a great opportunity to learn about new approaches to analytics and member engagement, as well as to hear about many of the creative initiatives health plans are implementing to improve quality scores and meet the complex web of risk adjustment requirements for Medicare Advantage, ACA, and Medicaid.

What’s the current state of payer-provider collaboration, and what does the future hold? Big questions to be sure, but we tried to find answers during a recent Availity-sponsored SmartBrief webinar featuring healthcare industry expert Jay Eisenstock of JE Consulting.

CMS has identified three drivers of directory deficiencies: group vs. provider-level data, lack of internal audits, and reliance on provider-led notifications. We've outlined these issues in an infographic.

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.

Recently, three trends have aligned to signal highly favorable conditions in the independent radiology space for the coming year. These trends are: (i) a resurgence of the patient steerage debate; (ii) an increase in patient consumerism; and (iii) advances in pre-service technology that could significantly improve practice efficiency. Independent radiology centers that take steps now to prepare will be in an enviable position next year and better able to capitalize on these trends.

Your health plan has enough claims to process without adding ones that don’t belong to your organization. But that’s what happens when claims with invalid member or provider IDs enter your adjudication system. Internal resources can spend significant time working these before the error is discovered, which means higher staffing and administrative costs.

Availity understands that if you want to drive provider engagement, you need to find new ways to automate healthcare transactions. That’s why we are introducing two new automated workflows within our Provider Engagement Portal: appeals and overpayments.

Join us Friday, 11/10 at 1pm ET for our tweetchat, Confidence Through Compliance, featuring our favorite HIPAA lawyer, Matt Fisher (@Matt_R_Fisher), and our Availity compliance guru, Erika Ables (@Erika_Ethics), as we discuss how compliance can enhance everything in healthcare from cybersecurity to patient interactions.