By Mark Martin
Realizing the promise of value-based healthcare will require a level of payer and provider collaboration virtually unheard-of in the recent past—and health information management (HIM) professionals play an essential role in achieving this reality.
To achieve success in the new value-based world, both payers and providers must work together to develop the most efficient means of sharing data, managing risk, validating provider credentials, processing claims, controlling costs, and optimizing the consumer experience. However, in the realm of provider data management (PDM), efforts directed towards payer-provider collaboration are expensive and time-consuming.
For example, each year it costs physician practices $2.76 billion to maintain provider directories—an average of about $1,000 per month per practice—according to a recent survey1 conducted by the Council for Affordable Quality Healthcare. Despite all the spending and allocation of resources toward ensuring accurate provider data, the industry often falls short, as shown by a recent report2 from the US Centers for Medicare and Medicaid Services (CMS). A CMS audit of Medicare Advantage provider directories revealed that nearly 50 percent of provider directory locations showed at least one mistake, with the most common errors including the wrong location, the wrong phone number, or an error in a directory stating that providers were accepting new patients when they weren’t.
Inaccurate provider directory information increases barriers to care for consumers, resulting in higher-than-expected medical costs when patients unwittingly visit an out-of-network provider. That’s why CMS issued rules in 2016 requiring all Medicare Advantage organizations and qualified health plans to verify the information in their provider directories directly with each provider at least every 90 days.
Updating directory information can require significant time and effort for providers, as most contract with a dozen or more health plans, and each plan may have its unique form and processes to follow.
To overcome this problem, HIM leaders are increasingly turning to multi-payer platforms to serve as a single source of truth for provider data. Multi-payer platforms are centralized portals that enable providers and plans to exchange and reconcile provider data. By using a single platform for providers to update and manage data for all of their contracted health plans, payers and providers can save time and money with streamlined processes and achieve better data quality and accuracy.
The Challenges of Accurate Provider Data
For both health plans and providers, maintaining accurate and up-to-date provider directories is an expensive and time-consuming process. Health plans and their networks are constantly changing, and providers frequently move, change jobs, or consolidate practices.
For providers, much of the challenge around updating information stems from each payer’s different questions and unique ways of requesting and accepting data. Many health plans, for example, update their provider data each year during their contracting and credentialing process, then feed that information into their provider directories.
The fragmented processes can result in a significant time and resource drain for providers. Each detailed provider record may track up to 380 distinct line items, such as service locations, billing locations, payment locations, specialties, certifications, affiliations, office hours, and languages spoken, according to one vendor analysis.3 After receiving updated information from a provider, the health plan generally sends an email to verify that information—which can divert staff from more important patient-facing activities.
As a result, some payers have launched their own portals, which hardly solves providers’ problem of having to submit the same data multiple times to multiple places. Using multiple portals is nearly as tedious and complicated for providers and staff members as the old days of submitting paper forms.
Multi-payer platforms represent a more convenient, intuitive option for providers. By delivering a substantial boost to providers’ efficiency, multi-payer platforms effectively incentivize providers to maintain current directory data.
Why Multi-payer Platforms Can Help
Multi-payer platforms provide a significant amount of value through their ability to leverage the strength and market participation of many health plans as well as access data across all health plans. Provider staff members who submit information do not have to worry about using different interfaces, menus, workflows, and commands because they’re the same across all participating health plans and, done well, the data analytics can help them reduce time by focusing on just the questionable data items.
Among HIM professionals’ most important contributions to multi-payer platforms is the development of machine learning tools that eliminate many of the frustrating manual processes associated with directory updates. These platforms are most effective when they’re also conduits for healthcare data beyond provider information, such as eligibility inquiries, claims, and payment data. Modern tools enable platforms to quickly capture essential provider detail changes, in part because multi-payer platforms aggregate and analyze provider activity across health plans, which helps them spot potentially inaccurate and anomalous data that would be missed by a single-plan system.
For example, imagine a scenario in which a doctor practices at locations A and B; the doctor started years ago at location A, but over time begins to perform the majority of their office visits at location B. In this scenario without a multi-payer platform, the physician’s staff would need to manually enter the location change in every single-plan system with which the practice contracts. In contrast, the machine learning tools of a multi-payer system would analyze the changing patterns of the location of the physician’s filed claims over time, flag the physician’s record as one that may need to be updated, and prompt system administrators to review and make any corresponding changes. This example illustrates multi-payer platforms’ ability to streamline workflows and enhance efficiencies for providers.
For health plans, the benefits of multi-payer platforms are similar. Each plan receives accurate up-to-date information in formats that their systems can consume and use. Further, plans don’t need to analyze submissions to verify that similar but unique specialty names, addresses, or certifications are consistently used.
Beyond Provider Directories
Multi-payer platforms are about more than just improving the quality of provider directories, though that certainly is one of their primary advantages. In the bigger picture, they’re about fostering better collaboration between payers and providers by enabling them to more effectively share quality and risk data—cooperation that will be increasingly necessary under current and future value-based arrangements. Through better information sharing, this increased payer-provider cooperation has the potential to lead to better patient care and outcomes.
McGrail, Samantha. “Providers Spend $2.76B Annually on Provider Directory Maintenance.” Revenue Cycle Intelligence, November 19, 2019. https://revcycleintelligence.com/news/providers-spend-2.76b-annually-on-provider-directory-maintenance.
Luthi, Susannah. “Medicare Advantage directories still riddled with errors.” Modern Healthcare, December 4, 2018. www.modernhealthcare.com/article/20181204/NEWS/181209985/medicare-advantage-provider-directories-still-riddled-with-errors.
Availity. “67% of U.S. Provider Organizations Update their Provider Data through Availity.” PR Newswire. www.prnewswire.com/news-releases/67-of-us-provider-organizations-update-their-provider-data-through-availity-pdm-300924795.html.
Mark Martin ([email protected]) is director of payer solutions, provider data management, for Availity.
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