By John K. Lamb | Tags: Provider Data Management
Health plans need all the strategies they can find to identify and eliminate inaccuracies in their provider directories. Insurers know how important the data in their directories is to members trying to find the care they seek, and recognize that keeping this data accurate is a complex and constant challenge.
While the teams who manage plans’ directories are already familiar with some common inaccuracies, we wanted to share 4 ways plans can continue monitoring the networks in their directories that may not be as top of mind.
1. Claims Activity
The absence of claims activity over an extended period is a red flag that warrants further investigation. If it’s been more than 3 months since a claim was last received, this may be a red flag that warrants more attention. If this time span extends to 6 months or more, this may be a sign of inaccurate provider data. This is especially true if the health plan has not validated the accuracy of the data for more than 90 days.
Members are either not using the provider’s services or a provider is no longer practicing at the location in question. The longer the gap in claims activity, the higher the chance of these scenarios occurring. Both scenarios can be verified by contacting the provider’s administrative office to determine the status of this individual, but health plans often lack the time and resources to do this systematically.
2. Active Provider Service Locations
All health plans are subject to access and availability standards that are intended to ensure members can see a provider without waiting too long. These standards are typically set by federal regulators for Medicare programs and by state regulators for Medicaid and commercial programs.
If a health plan lists more than 3-5 active service locations for a provider, this is typically a red flag as a provider can only be at one location at a time. If a provider were to overextend themselves by covering an excessive number of locations, they would not be accessible and available to their patients within a reasonable time frame. Health plans should monitor their directories for this condition and investigate whether providers are routinely scheduling appointments at these locations.
Healthcare organizations commonly list service locations where a provider may act in the capacity of a ‘covering’ provider to ensure claims are paid by insurers rather than risk denial for not recognizing the provider's association with a particular service location. Health plans should ideally differentiate between provider locations where appointments are taken, which should be listed in their directories, versus locations associated with a provider for claims processing which should not be included.
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3. Duplicate Provider Records
While excessive active service locations for a provider is one common reason behind provider directory inaccuracies, it’s not the only factor impacting the quality of provider service location data. Health plans typically rely on systemic automated control mechanisms to detect when errors may occur, with duplicate provider service locations being another common error. Typical reasons for this may be due to the quality of data shared with the health plan by a provider organization or simply human error in connection with manual data entry.
Yet another common reason for duplicate locations is when a provider has more than one office at the same address. In these instances, the distinction is often made by referencing a suite, room, or floor number. Health plans often list each unique combination of street address and suite, room, or floor as separate and distinct service addresses in their directory.
One way to address this issue is by using United States Postal System (USPS) address standardization. There are also data mining and analysis techniques, such as fuzzy logic or AI, that could be used to identify potentially duplicate address records so they can be corrected as soon as possible.
4. Mock Audits
It may be impractical to look at each of these problem areas individually, so a more comprehensive approach would be for health plans to periodically audit their provider networks using the same methodologies as regulators. If the sample directory data audited is randomly extracted from the larger pool of records, the number of errors identified in the sample should be representative of the whole.
For health plans, a Centers for Medicare and Medicaid Services (CMS) program audit failure can trigger financial penalties, sanctions, and even enrollment freezes. The results of a mock audit can help insurers identify issues and actionable remediation tasks before a real CMS audit identifies them. Performing a mock audit will ultimately enable health plans to gauge the overall accuracy of their provider data and work towards improving member experience.
In summary, ensuring accurate provider directories is vital for health plans to meet member needs. Strategies like monitoring claims activity, verifying active provider locations, detecting duplicates, and conducting mock audits are key. By prioritizing accuracy, health plans enhance member satisfaction, comply with regulations, and improve the healthcare experience for all.
About Atlas PRIME
PRIME is a service of Atlas Systems that offers a rigorous, proven approach to provider data validation and management. The PRIME goal is to help insurance plans deliver great member experiences – and stay in compliance with mandates like the No Surprises Act.
Atlas PRIME has achieved best-in-class status with a provider data accuracy rating of 95% through client-audited quality assurance and up to 90% validation success. Other services often rely on aggregated data, using sources of unknown reliability. PRIME takes a different approach. We deliver data validation from the source, reaching out directly to contracted health systems, provider groups, and individual practices.
John K. Lamb worked for over 40 years within major health insurance companies, taking on key claims, provider, and compliance issues. He is now Vice President of Provider Operations at Atlas Systems, working on our PRIME service.
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