How Payers and Health Plans Think of Identity and the Risks of Fragmented Data

On a recent webinar sponsored by Verato, panelists from SCAN Health Plan and Alliance of Community Health Plans responded to a series of questions relating to AI readiness and how to improve the quality of data.

Vinay Kulkarni, Chief Information Officer with SCAN Health Group, noted that healthcare is unique because identity involves a web of relationships where an individual or an entity, such as a provider organization, constantly changes roles depending on the context.

“Payers have to think about enterprise master person index (EMPI), alongside master data management (MDM), which most organizations have. Householding is a simple concept, but challenging to implement,” Kulkarni said. “Although financial systems have figured this out when people apply for a mortgage, they’ll tell you whether somebody in your household has applied for a loan. In that context, we have to think about members and caregivers. A single member identity must link clearly to their clinical history and their designated legal caregivers or authorized representatives. Similarly, one provider identity must link out to their physical location or a tax ID and unique digital health networked endpoints that they have, because their relationships with payers are different.”

Kulkarni added that on the member side, there are the same concepts for benefits and for pharmacies, leading to an identity crisis within health insurance companies. In order to confront this challenge, he advocated for adopting an EMPI to make it easier to identify the same person over several years.

Thomasina Anane, Associate Vice President of Enterprise Analytics with the Alliance of Community Health Plans, spoke about the human cost of getting patient identity data wrong, using examples such as prior authorization.