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.