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Provider Database Management: Getting it Right

By Priya Sabharwal, HGS Practice Leader, Network Operations; and Priyankar Bhattacharya, Senior Manager, Business Excellence

The nearly 8.8 million Americans who purchased healthcare coverage during the latest ACA enrollment season—along with the tens of millions who got coverage through other means—will be using their insurer’s network directories to find a provider.

Unfortunately, many of those members are in for a shock. Some will have selected doctors listed as accepting new patients but who are not. Others will find that their preferred doctors have retired or moved. Some will visit offices that were listed as in-network, but are not.

The number of inaccuracies found in many insurer’s provider directories are significant. A recent HHS survey uncovered errors in half of the listings in Medicare plans. States agencies have also uncovered widespread errors.

Inaccurate or poorly managed provider directories present significant challenges for health plans, including:

  • Dissatisfied members. Poor directories are more than just a hassle. They are critical barriers to care and the cause of unexpected medical costs.
     
  • Provider abrasion. Multiple departments of the typical health plan are already in regular—perhaps excessive—contact with providers’ offices for myriad data requests. Add provider directory requests to those, and you’ve got an acute case of abrasion.
     
  • Fines and penalties. The consequences for poor provider data management fall entirely on health plans in the form of stiff financial federal and state penalties and member lawsuits. For example, in 2016, CMS regulations permitted 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 ACA exchanges.

How does poor provider data management affect health system entry points?

  • Access centers
    • Poor provider data management hinders effective patient-provider matching, patient satisfaction, and demand conversion through call center.
  • Health system websites
    • If a health system's website does not contain robust, accurate provider information or reflect provider availability, online consumers may return to search engines for information and end up seeking care elsewhere.
  • Provider referrals
    • A lack of complete and reliable provider data about specialists leads to misdirected referrals and acts as a barrier to patient retention within networks.

What can hospitals and health systems do to build a provider data management foundation?

  • Establish a centralized provider directory.
  • Create a provider engagement program.
  • Develop a provider data governance strategy.
  • Make provider data accessible to key stakeholders.
  • Implement an analytics solution for provider network insights.

How BPOs Can Help

A mix of technology, automation, and business process outsourcing offers health plans an enduring and cost-effective solution to the provider data management problem. BPO organizations can bring strategic thinking and innovation to provider engagement data management, enabling health plans to compete more effectively under current (and ever-changing) market conditions. Here’s how:

Your BPO partner will begin by identifying the scope of the challenge and the health plan’s needs, which for the purposes of provider engagement would include:

  • Ensuring accurate provider and directory information to support compliance initiatives
     
  • Enabling differentiated client and customer network selection and new reimbursement capabilities
     
  • Validating and maintaining accurate provider demographic data

An experienced BPO partner will examine all the options to determine the best course of action. This may mean eliminating or revising a process (or parts of it) rather than simply applying technology to make an inefficient process more efficient. Understanding the goal, and then selecting the best method(s) to accomplish it, is at the root of an outstanding BPO partner relationship.

For example, deploying a provider database management system (PDMS) built by the BPO partner would capture relational elements of provider demographic data, ensuring that each element is accurately reported back, per compliance and regulatory requirements.

Another overarching reason to partner with a BPO organization is to quickly acquire knowledge and/or skillsets that do not currently reside within the payer organization. Rather than expending time and resources to get internal personnel up to speed, or going through a drawn-out hiring process, a good BPO organization can bring that knowledge or those skills to an organization immediately with limited lead time. This helps the payer meet current and long-term goals in a way that improves operations and customer satisfaction.

For example, trained call center agents in right-shore, nearshore, or off-shore locations would be deployed specifically for provider engagement. Leveraging a trained agent for provider outreach provides network physicians a single, human-based channel for relaying comprehensive data requests, eliminating multiple, often redundant calls from disparate departments. The goal of this best practice is collaboration. When health plans address the underlying problems of organizational silos, legacy systems, and manual processes, they make it easier for providers and health plans to share quality and risk information and reducing the number of requests to providers by asking the right person for the right information at the right time.

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