Accurate and up-to-date healthcare provider data is integral for health plans to guide their members towards the most appropriate care and for providers to deliver that care efficiently – ultimately reducing cost, improving quality of care, and improving outcomes.
Collecting and consolidating provider data (physicians’ names, practice locations, office hours, hospital affiliations, etc.) is crucial to making referrals, ensuring that claims get paid, as well as fulfilling any number of tasks on the patient care continuum for payers and providers. Interoperability has introduced several policies that necessitate the need to have an up-to-date provider directory. This obliges CMS-regulated payers to make key attributes from their provider directory publicly available via a standards-based API. For providers, there is now a focus on the Digital Contact Information Policy under which CMS is now publicly listing providers who do not list or update their contact information.
Building and maintaining a single, trusted repository of provider data that is up to date is critical to support the required directory updates. However, this cannot be treated as a one-time, manual exercise as provider data changes so frequently. A 2016 IDC Health report finds that 2% of provider demographics change monthly, with 20% to 30% of physicians changing affiliations each year, and 5% of doctors changing their status — losing their license, retiring, passing away, or receiving sanctions, for example — on an annual basis. The frequency at which these data change makes it all that more important for payers and providers to remain diligent in their directory maintenance.
Beyond changes originating from within your organization (payer or provider), provider data updates come from multiple external sources, such as national databases, state data, medical associations, third-party claims data, directly from a provider’s office, or from different departments within a plan. Integrating these external data together into existing systems can be challenging given that the systems support different processes.
Standards also change, as seen with the interoperability policies, which carry penalties for both payers and providers for failing to give access to up-to-date provider data. Currently, the financial penalties are targeted at payers who do not revise their directory within 30 days of a change or remove providers who cannot be verified.
New policies and laws being introduced continue to tighten the timelines for the update process; the 2021 Consolidated Appropriations Act (H.R. 133) further narrows the window for payers to apply updates to their directory down from 30 to 2 business days by 2022. Providers and facilities are also on the hook for notifying all plans of any material changes to their provider directory information in a timely manner.
Beyond CMS penalties, H.R. 133 further stipulates that if a patient relies on erroneous directory information, the plan cannot charge more than in-network rates and apply any payments towards in-network deductibles and out of pocket maximums.
Establishing a provider data repository (PDR) provides the organization with a single source of provider data that has been consolidated across various applications and integrated into a trusted view of the provider. PDR allows the business rules to tie these data together to later be defined by those closest to the data: stewards and other subject matter experts. Having all provider data in a PDR provides visibility into inconsistencies in the data across systems and aids in tracking data changes so that downstream applications can consume the changes they are interested in, at the frequency they can support.
IQVIA has found that it is difficult for many organizations to find the time and budget to invest in building their own PDR to meet their organization’s needs. Despite the challenges an organization may face, making an investment into a PDR can prevent inaccuracies within your system. For example, a Centers for Medicare and Medicaid Services review of 5,602 providers at 10,504 locations found that close to 50% of the provider directory locations listed had at least one inaccuracy, including providers at different locations than those listed, incorrect phone numbers, and providers not accepting new patients despite directories indicating that they were. Even a small discrepancy can be costly: $100 per day per individual who is adversely affected by a non-compliant qualified health plan, and as much as $25,000 per day per Medicare Advantage beneficiary.
Ultimately, patient care bears the brunt when provider data is disorganized; it can also only improve with an accurate, organized, and current PDR in place. In addition to providing advanced interoperability, a current healthcare PDR also enables quicker access to provider information at the point of care, improves care coordination, and fosters a better understanding of in-network providers. Good data governance helps to square providers’ relationships with other data entities — healthcare organizations, plans, specialties, and patients.
In order to get started down the path of establishing a PDR, you need to identify business initiatives or business processes that are significantly impacted by inconsistent, inaccurate, or incomplete provider data. These can be internal initiatives, like systems upgrades where the driver is reducing cost and increasing operational efficiency, or network expansion where the upside is increased revenue, or even external drivers, like provider directory mandates to avoid costly penalties from not having updates applied within 14 days.
IQVIA has helped many of our healthcare clients including hospital systems, physician groups, and healthcare payers, make the case for investing in PDR, establish a roadmap to full master data management, build their own provider data repository, and jump start data governance by establishing provider data stewardship. Click here for more information on how IQVIA can help you achieve your healthcare data needs.