By Priya Sabharwal, practice leader, network operations, HGS.
Imagine a scenario: A patient looking for a new doctor searches her insurer’s online network directory to find a provider her plan will cover. She selects what seems to be the perfect doctor based on her criteria, which could include gender, office location, languages spoken or other qualifications, in addition to being in-network with her health plan.
But there’s a plot twist: The patient eventually learns the doctor she found is not, in fact, the right option for her – but it took her scheduling and arriving at the appointment for her to realize this. It turned out the entry in her insurer’s directory was outdated, and her doctor had moved offices.
This scenario is hardly out of the ordinary. A 2019 Health and Human Services survey uncovered errors in half of the listings in Medicare plans alone. These significant inaccuracies cause issues not just for patients, but for payers and providers, too:
- Poor directories are more than just an inconvenience for a member; they also impede their access to necessary care, and can create unexpected medical costs.
- A typical health plan is already regularly contacting providers’ offices for many different types of data requests. When they also call to verify provider directory requests, it can create added pain for both sides of the equation. On the payer side, it can create provider abrasion, which could influence whether the provider keeps doing business with that payer. On the provider side, receptionists and office managers are pulled away from their higher-level tasks whenever they stop to answer the phone, leading to short-term frustration and, potentially, burnout.
- Payers risk incurring stiff fines and penalties from federal and financial entities, and/or member lawsuits. For example, as of 2016, CMS regulations now permit the agency to fine health plans up to $25,000 per Medicare beneficiary for errors in Medicare Advantage plan directories, and up to $100 per beneficiary for mistakes in plans sold on the Affordable Care Act exchanges.
- Poor provider data management hinders effective patient-provider matching, patient satisfaction, and demand conversion through call centers.
- If a health plan’s website does not contain thorough, accurate provider information, or reflect correct provider availability, potential patients may go back to the drawing board and select a provider from a different organization.
- A lack of complete and reliable provider data about specialists leads to misdirected referrals, and acts as a barrier to patient retention within networks.
So what are some steps payers and health plans can take to create a solid provider data foundation? It starts with fundamentally changing the way we think about, use, enter and maintain data.