Maintaining accurate provider data is essential for operations and fostering positive relationships between health systems and payers. It may seem simple, but it is a complex task critical to ensure fair reimbursement, support network adequacy, and promote quality of care and access to care.
While collaboration between health systems and payers is necessary to improve data accuracy, it can seem to be a nearly impossible task to accomplish without excessive administrative burdens on both sides, especially to meet the No Surprises Act (NSA) 90-day and 48-hour turnaround times. From revenue leakage to physician frustration and burnout, NSA compliance and member satisfaction, and even health outcomes — there’s much at stake when it comes to inaccurate provider data. Now more than ever, automated, agnostic solutions are needed to facilitate data exchange and ongoing updates for payers and providers.
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There’s a heavy burden for healthcare providers in the United States that requires them to deliver quality patient care while tackling burdensome administrative tasks. In fact, $400 billion is wasted on administrative complexities like navigating prior authorizations and coordinating benefits. That’s according to the latest CAQH Index Report’s analysis of healthcare expenditures in the U.S. A study by researchers from the University of Colorado School of Medicine and HiLabs found that manually sending directory updates to insurers via disparate technologies, schedules, and formats already costs practices a collective $2.76 billion annually. Not only is this costly, but it takes away from critical time with patients.
In addition to administrative burdens compounding physician burnout, the prevalence of outdated data is leading to missed opportunities to see new patients. When patients are unable to find providers to meet their specific needs, they turn to others who can. Each instance of incorrect data, such as an incorrect zip code, outdated office hours, or enrollment, influences a patient’s choice to select a provider. Outdated data directly translates missed opportunities with potential new patients, adding up to significant revenue leakage as time goes by.
Data dynamics and inconsistencies
But providers are not alone in navigating this delicate dance with data. The same study examined the reliability of physician information held within directories of five major national health insurers and found that 81% of entries had inconsistencies. These were most prevalent among address fields and physicians who practice at multiple locations. The high percentage further illustrates the significance of administrative burdens and the ripple effects of not addressing them. This includes preventing declining member satisfaction for payers. Patients want to know the cost deductibles, copays, and network providers so they can make better-informed decisions. Accurate provider data is necessary to ensure clear communication between members and health plans as well as NSA compliance.
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Empowering collaboration
Providers, payers, and patients all have a stake in this game. Aside from the administrative waste, there is a significant human cost at play here. Many patients do not have the luxury of waiting for care or for a centralized physician directory proposed by the Centers for Medicare & Medicaid Services to come to fruition, which could take years. The infrastructure to accomplish this is woefully lacking. Health systems and payers require more robust technological frameworks to support the transition to a unified provider directory. Agnostic, technology-enabled solutions are the only way to ease data exchange and synchronization processes. These are needed now to overcome the top challenges such as:
- Data fluctuations: Provider details ranging from location to specialties are prone to constant changes, while incomplete information and restricted networks add hurdles for patients seeking covered providers.
- Standardization challenges: With medical practices engaging with numerous health plans, each employing different methods of sharing provider information, the absence of uniformity complicates data exchange via disparate channels like fax, email, fragmented software platforms, and phone calls.
- Compliance hurdles: Current directors often lack mechanisms to identify non-compliant entries, posing challenges with regulatory adherence and data accuracy.
- Data overload: The implementation of the NSA intensified the need for providers to submit data more frequently to avoid non-compliance, placing a strain on health plans responsible for directory management.
Mastering the data dance to maximize value
Addressing these challenges encountered by providers and payers necessitates the adoption of neutral solutions for accurate data exchange. Simplifying, synchronizing, and automating provider data management for payers and providers at scale will help capture billions of dollars in lost revenue and allow providers to maximize the value of their provider network. Embracing data management platforms that centralize data exchange will play a significant role in alleviating provider burdens, enabling better member and patient experiences, and ultimately ensuring better outcomes for everyone.
Photo: Turac Novruzova, Getty Images
Eric Demers is the CEO of Madaket Health. He believes we can transform healthcare delivery through the power of data and interoperability. With more than 25 years of global healthcare experience, Eric has built and scaled leading technology and service companies, from early stage to Fortune 100. He is highly sought-after for speaking and consulting on international health, having advised global entities and governments on critical issues facing healthcare. A growth-minded leader, Eric has founded three companies and exited two. Eric previously served in strategy-focused executive roles at IBM, Accreon, MEDecision and Orion Health. He is a graduate of Brandeis University and The George Washington University School of Medicine and Health Sciences.
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