- Commercial health insurers spend $2.1 billion a year to maintain provider databases, three-fourths of which could be avoided by integrating with an external data source, according to a new CAQH white paper.
- Now CAQH and a group of insurers, hospitals, health information exchanges and others are offering a roadmap to guide development and implementation of an industry solution.
- Challenges include defining the meaning of provider, which has evolved beyond physician, hospital and allied health professional to include others who deliver or coordinate care such as nurse practitioners, social workers, addiction counselors, community health centers, behavioral health centers and other community-based organizations, the paper says.
Failure to keep directories up to date can cause myriad problems, from patients choosing an out-of-network doctor to not knowing a physician isn't accepting new patients or Medicare patients or has moved to a new location. This can contribute to surprise medical bills, invoices with unanticipated costs because a patient inadvertently received care outside their insurer’s network.
Inaccurate provider information can also impede sharing of patient information and raise health plans’ administrative burden and costs, the white paper notes.
The roadmap — a collaboration of CAHQ and the Provider Data Action Alliance — identifies five key ingredients for a provider data solution:
- An industry-wide commitment to tackle the problem;
- A not-for-profit, multi-stakeholder governance framework;
- A common basic data set and quality standards;
- Interaction with regulators to ensure future policies and standards align with the industry solution; and
- Measures to assess the value, cost and overall accuracy of the solution.
More than half of U.S. doctors report seeing patients each month with health coverage issues related to inaccurate directories of in-network providers, according to a recent survey by the American Medical Association and LexisNexis Risk Solutions.
Nine in 10 of physicians surveyed said having accurate information in network directories is important, and 67% said they would favor a single, centralized interface to simultaneously update director information for multiple payers and health plans.
It’s not just private payers that face this problem. A recent CMS report found 52% of provider locations for Medicare Advantage plans were wrong. The agency sought more oversight over MA directories after learning of problems in an earlier review.
“It’s problematic for both sides,” Robert Tennant, director of health IT policy at the Medical Group Management Association told Healthcare Dive in an interview last year. While plans need to ensure sufficient network access for their members, physicians struggle to keep up with constant, often overlapping request for information.
According to the white paper, the typical medical practice maintains 12 managed care contracts at any given time, each requiring about 140 different provider data elements for contract management. For a practice with five physicians and 12 contracts, that translates to 8,400 data points.