One Health Plan’s Practical Example with Provider Directories

In a recent blog, we looked at provider directories, regulations around them, and fines levied against health plans for inaccurate directories.

Now, we’ll look at how one organization improved the accuracy of its provider directories and the success it’s now realizing which has led to other initiatives focused around improving the quality of its data.

Provider directory accuracy

The company manages both a health plan and a network of providers (a.k.a., the clinical enterprise) and maintains separate provider directories for each. The health plan directory, which is primarily used by health plan members to find providers in their area who accept their specific insurance plans, contains around 35,000 providers. The clinical enterprise directory contains roughly 4,000 providers and is used by patients seeking care to find company employed providers or company owned locations offering the health care services that they need.

Unfortunately, inaccurate information displayed on these provider directories (e.g., incorrect practice locations, wrong phone numbers, providers being listed as accepting new patients when in fact they weren’t) had caused this company to fail a Center for Medicare & Medicaid Services (CMS) audit and not correcting the inaccuracies would have resulted in a hefty fine.

According to the CMS regulations, health plans selling Medicare Advantage plans can face fines of up to $25,000 per beneficiary for each provider directory error.  This means that a single error affecting 1,000 beneficiaries could lead to $25 million in fines. Alternatively, inaccuracies in provider directory data for plans sold on the healthcare.gov website can result in fines of up to $100 per beneficiary/day.  In this case, 1,000 affected beneficiaries could result in up to $100,000 in fines.

Further compounding this organization’s data quality issues was the fact the clinical enterprise and the health plan both maintained their own provider credentialing systems (used to track information on providers’ degrees, fellowships, board certifications, practice locations, etc.) which were directly feeding data to their respective provider directories. This sometimes led to conflicting information being shown across the two directories for the same provider.

Provider Repository

To address these issues, the company’s data governance team brought in IQVIA’s Healthcare Center of Excellence (COE) (HighPoint) to build a Provider Repository that would act as the source-of-truth for any provider data that needed to be shared outside the organization (i.e., the provider directories). However, due to time and budget constraints, the decision was made not to implement a full master data management (MDM) solution, but rather use the organizations existing Informatica tools (primarily PowerCenter and Informatica Data Quality) to implement some “light mastering” of the provider data.

To do this, data was extracted from the two credentialing systems then transformed into standard layouts, matched across systems and combined into a single record.

The reason we consider it “light mastering” is because only basic match rules are applied, and merging was done at an entity level, rather than the data element level, based on source system precedence rules. Furthermore, only rudimentary auditing, cross-referencing of source data and error reporting was implemented.

IQVIA’s Healthcare COE (HighPoint) was also able to help the data governance team find and address several data accuracy and quality issues during building the Provider Repository.  We then helped them design and implement business and technology-based processes that would, in the future, identify and alert them to similar issues before they made their way into the Provider Repository and any downstream extracts.

Some major benefits of the Provider Repository include:

  • Automatically integrates provider data from multiple sources
  • Automatically generates and sends provider directory extract files to external vendors (i.e., no more manual uploading into the provider directories)
  • Identifies data that does not conform, either in content or in structure, to pre-defined business rules and alerts Data Stewards for correction
  • Ensures that the same data is displayed across both directories for the same provider by acting as the approved source of data for all downstream systems
  • Conforms individual source system code sets to approved, standardized code sets

However, the greatest benefit of the Provider Repository is the confidence the company has that the data displayed on both provider directories is accurate and consistent. And over time, additional sources of provider data can (and already have been!) added to the Provider Repository to help further improve both metrics.

Outcomes

With the Provider Repository up-and-running and new data governance processes in place, the data governance team was able to show significant improvements in the quality and accuracy of the provider directory data to executive leadership. Some of the most notable improvements to data on the provider directories include:

  • Only listing practice locations where patients can book appointments with providers
  • Only showing phone numbers that members can use to book appointments
  • Display only those providers and locations accepting a selected plan
  • Removal of insurance plans that a selected provider doesn’t accept

The data governance team has been able to use the success of the Provider Repository to secure funding to purchase enterprise class MDM tools and stand up their first two MDM domains (currently being implemented by IQVIA’s Healthcare COE).  While this MDM solution will ultimately make the Provider Repository obsolete, we’ve been able to leverage much of what we’ve learned (about source systems, data entry and maintenance processes, about the internal operations of the company, etc.) and built for the Provider Repository (reference data, standardization rules, match and merge rules) to help speed up the implementation of the initial Provider and Location domains.

Data governance

Provider directories, like other data assets a company possesses, function best when incorporated into a larger data governance framework. Failure to do this prevents companies from having a complete understanding of the journey that provider data takes as it travels throughout the organization. This, in turn, prevents them from truly having control over how that data is collected, maintained, and used (both internally and externally).

Once a company has this intimate understanding of its data, it can then develop policies and processes, as well as implement technology-based solutions, to not only catch bad and inaccurate data before it’s exposed to the public, but ideally also prevent it from being entered into the source systems in the first place.

Below are some questions to consider when building data governance around provider directories:

  • How is provider data collected and verified?
  • How is provider data maintained once entered into the operational systems?
  • What other systems or platforms handle provider data before it ends up on the provider directory?
  • What business rules and transformations are applied when data is loaded into and extracted from any upstream systems?
  • What process does each upstream system have in place for ensuring data quality?

The earlier a company can catch and address inaccurate or poor-quality data, the less impact it will have on their business. Publicly exposing data, as health plans do with provider directories, creates the risk that regulators or members could find inaccuracies in it. These inaccuracies can lead to fines from the regulators and/or damage to the company’s reputation with its members and within the larger healthcare marketplace. Healthcare organizations that pay attention to what is being displayed on their provider directories and understand the processes, both within and outside the organization, used to get it there can reduce these risks.

Check back later for additional information on implementing an MDM solution.

To learn more about the IQVIA Healthcare Center of Excellence Informatics practice, please reach out to Justin Washburn, vice president, Healthcare Data Management.

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