Provider Directory Inaccuracies Are Only a Symptom

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Vice President, Enabling Partnerships

Spoiler Alert: Looking for a new doctor? Pick a door…any door…literally.

The results are in from the latest Centers for Medicare and Medicaid Services (CMS) Medicare Advantage Provider Directory audit. And they are not impressive. The number one problem plaguing provider directories is location (hence my title).

CMS evaluated against 11 key criteria during the review, and identified deficiencies by type. All in all, most of the deficiencies are related to basic provider location, plan acceptance, and phone information. I don’t think the industry imagined that something so basic would be so difficult to confirm and report out.

The bottom line results are that despite the focus, time and effort spent by health plans attempting to solve this dilemma, the most basic information is significantly inaccurate.

Location Wasn’t the Only Problem Area

As noted in the last review, the three most common drivers of provider directory deficiencies, in a nutshell, continue to be:

  1. Groups are listing providers at a location because the group has an office there, even if a given provider rarely or never sees patients at that location.
  2. Medicare Advantage Organizations (MAOs) are placing full faith in credentialing services, vendor support and even in provider responses, which CMS considers to be unreliable practices.
  3. Lastly, health plans are incorrectly assuming they will be informed proactively of a needed change. CMS suggests that plans proactively reach out and use data available such as claims to identify inactivity.

CMS is holding payers accountable, regardless of where the information is coming from and the process used. Fines are expected to start rolling out this year.

What are your options?

  1. You can focus on tuning and improving your inbound roster handling. But you have to place your trust in the groups to provide you trustworthy provider location  information and is susceptible to issue number one above; or
  2. You can launch full scale outreach, asking groups to review and update what you are showing in your directory. While some of the groups will do this, some simply push back and insist you refer to the roster they sent you.  Either way, you are then susceptible to either issue number one or two above; or
  3. Lastly, you can apply analytics or machine learning, using the data already available, then follow up with strategic and informed outreach based on those analytics.

It turns out that CMS made a significant suggestion that aligns with option 3:

“Through the insight gained from our reviews, it has become clear that a centralized repository for provider data is a key component missing from the accurate provider directory equation.”*

It’s comforting to know that in spite of the discouraging results of the audit, a centralized repository exists and the very thing CMS is saying needs to be done is the very thing we do.

At the end of the day, provider directory inaccuracies is a symptom. The real problem is inefficient, fragmented provider data management strategies. I’ve worked with provider data for a long time and one thing I know for sure, if the underlying process for managing the influx of provider data is broken – the dependent work streams and deliverables like directories will never be right.

As a matter of fact, we have an upcoming webinar that addresses this very thing. Join if you can. Click here to register.

The DNA of Healthcare

At LexisNexis Risk Solutions, our goal is to provide the healthcare industry with insights and innovations to improve outcomes, grow market share, reduce fraud and increase compliance.

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