8 Focus Areas for Accuracy of Provider Data Management that Impact Payment Accuracy

Managing a network of healthcare providers presents many challenges. Given the wide variety of data collected, maintained, and distributed by network management teams, maintaining a network’s provider data can become a nightmare when not managed effectively. Even small gaps and inefficiencies in data management can cause major issues across the health plan, especially when not quickly addressed.

Errors in provider data account for the top reasons’ claims are pended or processed incorrectly, leading to frequent reprocessing and even potential fines, often attracting unwanted attention from providers, members, and regulators. This can be frustrating, given the widely accepted belief that quality provider data is difficult to collect, validate, and update within reasonable turnaround times. Many plans are forced to rely directly on providers to submit rosters of data, which are often not the group’s top priority to maintain or distribute. Even when relying on delegated groups and IPAs, it can be challenging to receive accurate data at the required frequency from providers. 

Below are identified areas of PDM pain points and the ongoing and evolving challenges they face:

MEMBER ABRASION 

As with all areas of payer operations, the primary objective is to ensure adequate care is being provided to members. Members need access to an accurate list of in-network specialists. They must feel confident that they are assigned to an appropriate primary care physician. They need to access and understand provider directories to locate urgent care facilities and clinics for rapid-response treatment. Any gap in provider data that leads to a member having even a slightly difficult experience locating or receiving healthcare must be treated as a critical risk to payers, even if it is as “simple” as incorrect provider demographic information such as suite or telephone number. If these gaps are not remediated, the impact on members can quickly snowball to become catastrophic.

PROVIDER ABRASION 

Keeping providers happy is a critical goal of health plans. When providers join a payer’s network, they expect their information and data to be managed with the utmost care. Every physician, facility, pharmacy, and lab must be accounted for in a payer’s system. Any inaccuracy may lead to issues including incorrect claims payment, authorization issues, PCP assignment issues, publishing incorrect data in a provider directory, the list goes on. If a provider feels their data is not being collected, stored, and updated in an accurate and timely fashion, that provider becomes a risk. In their view, these errors are not just inconsiderate to them as providers but are also dangerous to members. Whether choosing to act on their own behalf or in defense of their patients, providers will not hesitate to raise concerns if they feel a health plan is not maintaining their data at a high standard. In these instances, they will not hesitate to amend or terminate their contracts, alert regulators, or take legal action.

STATE/REGULATOR ABRASION 

Maintaining a good relationship with regulators is crucial to any payer looking to maintain or expand their current book of business. Generally, this relationship is managed by specific teams that are responsible for producing reports, sharing information, and providing updates to specific regulators. However, this department is not usually responsible for the maintenance of accurate data, as they rely on a PDM team. Due to the demanding nature of many regulators, other teams typically don’t have the time or resources to validate the accuracy of the data they use to respond to regulators’ demands. They run the risk of being caught off guard when regulators bring up issues that have been escalated to them from members and providers. It may not be immediately obvious from where these issues stem and performing root cause analysis is often time-consuming and expensive. In order to keep regulators happy, it is critical for all teams to have a high degree of confidence in the provider data that they use.

CMS ABRASION 

Everyone fears a CMS audit. Similar to state and local regulators, CMS and the federal government have a say in how provider data should be maintained. In fact, it is common for federal, state, and local requirements to be in conflict with each other, which creates challenges for the PDM team that is trying to manage a large network. In any case, PDM teams must have documented policies and procedures that comply with all levels of government oversight, while simultaneously meeting contractual obligations, provider requests, and internal corporate goals. Once these are established, payers need to face the challenging task to develop processes, metrics and quality checks that accurately measure the PDM team’s performance on meeting these requirements. 

NETWORK ADEQUACY AND ACCURACY 

Finding out that your network has gaps can be scary. Any issues in network can escalate from any of the previously mentioned groups, and any suspected issues in your underlying data must be promptly remediated. However, before those issues can be resolved, fingers will be pointed, and blame assigned. More often than not, the PDM team is an easy target because they manage the overall provider data, and as a result they are accountable for any and all gaps in accuracy, regardless of providers and other departments that share in the responsibility to exercise checks and balances leading up to the current issue at hand.