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The importance of maintaining accurate health care provider information

4 min read


(Photo:Tom Suk, Senior Director of Provider Data Solutions, LexisNexis)

This post is sponsored by LexisNexis® Risk Solutions

 As more consumers enroll for benefits and seek care, having access to accurate and up-to-date information on the doctors servicing them is critical. Tom Suk, Senior Director of Provider Data Solutions at LexisNexis, is responsible for directing and developing the company’s provider data management products in order to help with these challenges. He also oversees application development and delivery, product quality assurance, technical infrastructure and data acquisition.

He spoke with SmartBrief about some of the challenges of maintaining accurate information and how health plans can solve them.

Question: Why is having accurate provider information so important for patients and the industry?

Tom Suk:  As more consumers enroll for benefits and seek care, having access to accurate and up-to-date information on the doctors servicing them is critical. Consider a consumer dependent on public transportation – to that person geographical location is critical in coordinating his or her care. The same is true for languages spoken, hours, specialties, ability to see new patients and more. All of this information affects how consumers access and utilize care. If this or other types of information are incorrect, there are waterfall effects that not only impact the individual patient but also other entities such as payers that are responsible for the administration and coordination of benefits across the programs they offer.

Q: Why is provider data such a challenge for health plans?

TS: Provider data changes constantly. At LexisNexis, we see 33,000 primary address changes weekly, 30% of doctors change their affiliations each year and 5% of doctors change their status annually. This information is often dispersed throughout the payer organization to serve specific purposes (billing, credentialing, network directories, contact info, etc.). Compounding the situation is the consolidation of the industry as networks acquire other networks. Payers focus on delivery and coordination of care and are not necessarily experts in data management, linking, de-duplication, standardization, or monitoring changes across their provider data. Managing provider information requires a strong infrastructure including experienced data stewards, systematic processes and automation — and that is just to start. Unfortunately most health plans are not in a position to build that type of infrastructure if it’s not already in place. For those that have a framework up and running, it still proves difficult to stop long enough to identify and address gaps.

Q: What is driving this push for provider directory accuracy?

TS: Historically, the desire to avoid member dissatisfaction tied to inaccurate information being published was enough. More recently, CMS issued a mandate in February 2015, making inaccurate provider directories a matter of non-compliance – not just member dissatisfaction. To stress the seriousness of the matter, CMS has tied fines and other disciplinary actions to non-compliance. We have also seen individual states begin to issue similar and in some cases more aggressive requirements for health plans serving their communities.

Q: What role does technology play in solving this problem?

TS: The right technology, analytic approach and service offerings are critical to navigating these new regulations successfully. A strong technology platform is paramount to ensure that the assimilation of attested information is properly identified; linked and tied to the right providers; updated quickly across directories; and enables heavy processing of claims data to monitor a provider directory.

Q: How can plans be more proactive in updating provider data?

TS: The key will be employing an automated and systematic methodology to monitor claims activity and other important data sources for changes that the health plan will be able to act on.

For more information about LexisNexis® or this topic please contact, [email protected] or call 866.396.7703.