Are you a healthcare payer grappling with inaccurate provider directories? If you are responsible for generating provider directories on demand and at enrollment, the following situation may sound familiar. A plan member calls your customer care team, furious about unexpected charges for seeing a specialist. After researching the issue, your customer care agent identifies the problem. Turns out the specialist is an out-of-network provider.

“That’s impossible,” the caller sputters. “I got the name of the specialist from the provider directory you gave me.” The plan member proceeds to list several other issues with the provider directory. The specialist was actually the eighth one on her list. The addresses for three specialists were incorrect and the phone numbers for two more were disconnected. Three other specialists weren’t taking any new patients. At the end of the call, the plan member thanks the customer care agent, but the next time open enrollment season rolls around, she chooses another company for her health insurance.

An Industry-wide Problem

If inaccuracies in your provider directories are hurting your bottom line, you’re not alone:

  • A recent CMS audit found that almost 49% of provider locations contained at least one error and 41.75% of locations contained inaccuracies that posed the highest likelihood of preventing access to care.
  • Ribbon Health recently conducted a poll about the accuracy of public use files (PUF) for plans on Individual Exchange Marketplaces. The results revealed that these directories contain even more inaccuracies than those for MAOs.
  • According to a study published in Health Affairs, healthcare beneficiaries in California have only a 30% chance of scheduling an appointment with an in-network physician.
  • The Integrated Healthcare Association (IHA) of California found that 31 percent of providers that should have been listed in a health plan’s online directory were not there.

Inaccurate provider directories are a big enough problem that they’ve captured the attention of state and federal governments. In July 2016, California’s SB-137 took effect, requiring health plans and health insurers to provide plan members with a complete and accurate directory of contracting providers. While the original bill required payers to publish directories with 97% accuracy, the current bill does not contain a minimum accuracy threshold. However, California indicates that it may impose penalties for inaccurate directories in the future. CMS has also taken note of the problem, issuing compliance actions to all but two MAO’s with inaccurate provider directories during the most recent audit.

Looking for Answers

As regulatory oversight increases and plan members grow increasingly frustrated over the difficulty of finding in-network providers, healthcare payers will need to do a lot better when it comes to provider directories. In a previous post, we mentioned some of our best practices for addressing the issue:

  • Develop a single source of truth for all provider data
  • Adopt a centralized, cloud-based approach to data consolidation and plan creation across the organization
  • Automate the creation of provider directories by using master templates, versioning, and variable business data across plans
  • Eliminate manual processes by using data to automate the provider directory creation
  • Take the initiative – don’t assume that provider networks will update you with their change of information

Faced with growing calls for reform, industry insiders are coming up with their own solutions. In 2018, IHA launched the Symphony Provider Directory, a centralized online platform where providers and plans can submit, update, and reconcile provider information. The initiative is in line with recommendations from CMS calling for a centralized provider database for Medicare Advantage plan sponsors to replace the current system, where each sponsor maintains its own information.

While public insurance programs are looking to cloud-based solutions, private insurers see blockchain as a potential cure for their provider directory woes. The Synaptic Health Alliance, a group composed of seven leaders in healthcare, is developing a private blockchain system to enable decentralized databases to link up and update shared data. Whether insurers invest in a cloud-based, centralized database or blockchain technology, they face the formidable challenge of mapping and integrating with payer and provider systems. Creating a diverse ecosystem of compatible solutions will be key to the success of these initiatives.

The Missing Piece of the Puzzle

What many healthcare payers are overlooking is the communication and delivery piece of the puzzle. By investing in a cloud-native CCM solution that connects with next-generation data, healthcare payers will have some powerful tools to combat inaccurate directories. Foremost among the benefits of cloud-native CCMs is the ability to automate approval workflows.

Traditionally, healthcare payers have relied on manual processes like email to share, review, and approve provider directories and had to start from square one to automate their approval workflows. By contrast, a cloud-native CCM solution that maps to internal approval processes can automate approval of directories more efficiently than manual processes. Selecting a qualified vendor can also streamline the automation of approval workflows.

The ability to automate documents is especially valuable for small to medium healthcare payers. While enterprise payers may have multi-person, cross-functional teams to manage member communications, small to medium payers may rely on a single employee. Simply managing monthly updates to provider directories can eat up 1-2 weeks worth of work, with no time off for busy enrollment seasons. Having Shared Services that include cloud-native CCM and a Digital Ecosystem that connects to the provider directory data source and uses business rules and master templates to automate the creation of the provider directories allows even the smallest teams to become more productive and meet timeline challenges.

Increased government scrutiny and tighter regulations make generating accurate provider directories more important than ever. While investing in technology like blockchain and centralizing databases will address the issues of siloed and inaccurate data, payers also need to invest in the communication side of the equation. By adding a cloud-native CCM solution that integrates with internal systems, healthcare payers can streamline the process of generating accurate provider directories from start to finish.