Why is Provider Data Management

Critical for Payors?

The demand for quality Provider data is more crucial than ever, as healthcare swings from a
fragmented, fee-for-service model to a highly-coordinated, value-based delivery system.
Provider directories remain mostly siloed and inaccurate, creating challenges among Providers
and Payors for referral claims and care coordination.
Managing provider data is essential for referrals, claims payment, Payor contracting,
administrative efficiencies, and member satisfaction. Providers and Payors collectively spend
more than $2.7 billion annually to maintain their Provider data integrity. Additionally, federal
and state regulators have increased penalties for Payors with data inaccuracies. To avoid these
penalties and improve these processes, our healthcare systems are reassessing ways to manage
Provider directories. 

Provider Data is Difficult to Manage

Provider data is continuously changing and, as a result, demands around the clock attention to
ensure information is accurate and up to date. 

 2% of Provider demographics change every month. 

 20%-30% of physicians change their affiliations each year. 

 52% of the Provider directory locations listed were found with inaccuracy by CMS
Other underlying issues include limited authoritative sources, the variation of requirements and
standards, and lack of Provider engagement. Further, as health systems merge or expand with
acquiring more physicians, Payors lose control of their Provider Data quality.

Implications for Members

Members suffer when Provider data is outdated, disjointed, incomplete, or inaccurate. These
inaccuracies pose a significant barrier to accessing care. 

 Nearly 42% of all locations found inaccuracies with the highest likelihood of preventing
access to care.

 Over half of U.S. physicians encountered monthly health insurance coverage issues due

to in-network physicians' inaccurate directories.
Agile Provider Network Management Solution to Assist
Employing an enterprise-wide Provider network management solution is one of the best ways
Payor organizations can address the Provider data management problem. Payors can use
Provider network management solutions to reduce unnecessary costs and inefficiencies while
improving Provider and member satisfaction.
An agile enterprise-wide solution should have the following features: -

 Build Provider data as an Enterprise asset by allowing all stakeholder's within the
organization like Recruitment, Credentialing, Contracting, Claims, and care management
to view/ update and leverage 

 Capability to onboard Providers by seamlessly fetching Provider data from Industry

Sources (e.g.: - NPPES, Pitney Bowes, CAQH) to expedite Provider
Onboarding/Enrollment and maintaining consistent data set.

 Build Provider inclusivity by Allowing Providers and their Practice Administrators to

come online and review/update their records along with administrative control to
approve change requests made by external stakeholders

 Deploy Intelligent Algorithms to match, cleanse and standardize providers to avoid

duplicates and error-prone records 

 SaaS-based platform to empower network managers to effectively and transparently

manage all of the various network management activities outlined above, maximizing its
productivity/yield

Benefits

 Accurate, up-to-date, and standardized Provider data

 Faster claim processing and Provider satisfaction

 Greater interoperability for accurate Provider data exchange

 Reduced administrative tasks in gathering and retrieving Provider data

 Improved member experience & Net Promoter Score (NPS)

 Maximized compliance
Utilizing Provider Network management solution, Payors can have confidence that their
networks are doing what they need to, faster and more accurately. It can help your institution
eliminate Provider data inaccuracies that lead to financial penalties, lost revenue, delayed
reimbursement, denied claims, and improved member and Provider experience.
References: - 
1. https://www.healthdatamanagement.com/news/inaccurate-data-on-providers-
continues-to-dog-payershttps://www.cms.gov/Medicare/Health-
Plans/ManagedCareMarketing/Downloads/Provider_Directory_Review_Industry_Report
_Year2_Final_1-19-18.pdf
2. https://globenewswire.com/news-release/2018/02/27/1396149/0/en/Physician-
Survey-Reveals-Need-for-Physicians-and-Health-Plans-to-Work-Together-to-Ensure-
Better-Network-Directory-Accuracy.html
3. https://www.cms.gov/Medicare/Health-
Plans/ManagedCareMarketing/Downloads/Provider_Directory_Review_Industry_Report
_Round_3_11-28-2018.pdf 
4. https://www.caqh.org/sites/default/files/explorations/CAQH-hidden-causes-provider-
directories-whitepaper.pdf