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Provider Data: Leaving Patients in Limbo?

provider data
Senior Director, Product Management

When a patient tries to track down a physician using a provider directory, it often becomes a scavenger hunt. A provider might not be at a listed location, no longer be part of the patient’s insurance plan, have an incorrect specialty, or not be taking new patients. And too often, that’s where the search ends. A surprisingly high number of referred patients simply abandon course rather than pursue correct contact information through other sources.

Quality provider data is very important to healthcare organizations. In fact, in a recent survey[1]we conducted with data governance decision makers in provider organizations, 63% of respondents said that proper data governance improves care coordination across practices. These leaders also noted its importance to strategic planning (31% of respondents) and marketing (22%). Even so, organizations seem limited in their ability to maintain high quality provider data:

  • 44% of our survey participants lament not having the resources to support proper data governance.
  • 46% said there is no single person or department responsible for the data, although primary decision makers were identified as C-level executives (51% of responses), department heads overseeing data analytics, IT, EHR system administration, and other functions (30%) and director-level professionals in data science, data quality practice and other roles (11%).
  • 33% of those surveyed said they can’t identify a single source of truth.

Our survey comprised a relatively small sample of organizations, but the results are consistent with larger studies conducted by the Centers for Medicare & Medicaid Services (CMS) and academia.

Looking at over 5,600 providers in 10,500 locations selected from online directories of Medicare Advantage Organizations, CMS found that 49% of the listed locations had at least one inaccuracy. And 42% of all locations featured misinformation that posed the highest likelihood of preventing access to care.[2]

When researchers from Yale University and New York University conducted a national survey of privately insured patients who received mental health treatment, they found that 44% had used a mental health provider directory and 53% of those patients encountered directory inaccuracies. The latter group was 4 times more likely to receive an unexpected out-of-network bill due to the misinformation.[3]

A Care Continuum (Potentially) Cut Short

Data inaccuracies create problems for patients – who become lost in the system – and for providers, who lose confidence in their ability to make proper referrals and risk losing the trust of their patients. In the extreme, a patient may grow frustrated enough to disengage from the healthcare system. The COVID-19 pandemic also brought to light the importance of having accurate data at hand as increased patient volumes necessitated intense and well-coordinated care.

Aside from health concerns, bad data can have financial implications for the patient. Consumers often select providers based at least in part on “in network” participation. When they inadvertently go out of network, their bill can be multiples higher. And the health system suffers from revenue leakage.

It’s Time for a Provider Data Governance “Care Plan”

Referring back to our survey, only 18 percent of participating organizations have a dedicated data governance department responsible for provider data. While organizations have managed to “get by” with the status quo, changing conditions will likely bring a new sense of urgency to “get it right.” COVID-19 is far from over; an expected second wave and flu season makes it a double whammy. The healthcare system will continue to be stretched to the limit. Managing provider data is more critical than ever. 

Provider data governance should be treated with the same critical importance as patient data governance to help achieve increased revenue growth, improve workflows and contribute to better patient outcomes. It has to start with an acknowledgement of the issue and a commitment to solving it.  The first crucial step is identifying a central owner of the data who understands the nuances of changing data and has the appropriate governance and sourcing strategies to enable success. To learn more about the provider data challenges we uncovered, check out our recent study results white paper, “Accurate Provider Data Governance Essential to Patient Care”.

[1] LexisNexis® Health Care Provider Data Governance Survey, August 2020

[2] CMS, Online Provider Directory Review Report, published November 2018

[3] Health Affairs, Incorrect Provider Directories Associated With Out-Of-Network Mental Health Care And Outpatient Surprise Bills, June 2020

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