Bad Data Causing a Host of Ills for Healthcare Consumers & Payers

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Payers are struggling to maintain the accuracy of information contained in their directories and networks, and because of these problems, healthcare consumers are not able to gain sufficient values from their information.

Data practices and consolidation of fragmented information would bring significant benefits to payers, which are under increasing pressure to improve the information they present to consumers, according to a recent report from IDC Health.

Consumers expect payers to make available quality provider data, contends Jeff Rivkin, research director for payer IT strategies at IDC Health Insights. However, he argues that payer directories continue to be inaccurate, out of date, and generally hard to use.

By publishing directories online, health insurance companies hoped to solve some of these problems. Nonetheless, according to Rivkin, it only served to highlight for consumers the poor quality of directory data. Because directory data tends to be inaccurate, members are likely to be hit with out-of-network charges; patients are not able to find providers that accept new patients; and overall consumer satisfaction is declining.

“Customer engagement with payers starts day one with the patient seeing if their set of doctors is local, in-network, available for new patients, speaks their language and is available to them conveniently,” says Rivkin, who authored a new report from IDC detailing the problem. “If that consumer information is later found to be inaccurate or inadequate, a payer’s brand is tarnished forever. Now, with the increase of the individual marketplace, consumers will go elsewhere.”

The IDC report cites one vendor who contended that in its survey of 200 U.S. health plans, payers were only 55 to 70 percent accurate on critical directory fields.

Rivkin makes the case that inaccurate, inadequate provider data is no longer acceptable in this increasingly litigious, regulated, consumer-focused and competitive environment in which payers are operating. Consequently, he believes health insurers should be prepared for increased network adequacy and directory quality audits from the Centers for Medicare and Medicaid Services. In addition, California, Maryland, New Jersey, Vermont, and Washington, D.C., now require proactive verification of provider information.

“The fines are coming; the audits are happening,” Rivkin warns.

In California, for example, 12.5 percent of physicians in Anthem’s directory weren’t at their listed locations, and nearly 13 percent were not accepting state exchange patients. As a result, Anthem and Blue Shield were hit with a ruling in November 2015 that forced them to rebate $15 million in charges for out-of-network charges related to inaccurate information.

An adequate network includes providers that can address a variety of patient healthcare needs and deliver the services that the plan covers under its benefits package, Rivkin notes. Specifically, he asserts that “network adequacy" refers to a health plan’s ability to deliver benefits promised by providing reasonable access to a sufficient number of in-network primary care and specialty physicians, as well as all healthcare services included under the terms of the contract.

Consequently, from the perspective of insurers, maintaining the accuracy of their directories is imperative for their own success, Rivkin contends.

But payers are not totally to blame. Provider data is constantly changing and therefore very difficult to keep up to date. The IDC report notes that 2 percent of provider demographics change each month; 20 to 30 percent of doctors change affiliations each year; 5 percent of doctors have a status change each year—they lose their license, retire, die or are sanctioned.

Rivkin observes that because regulations are increasingly targeted at payers, insurers are actually putting pressure on providers, who are the source of the bad data. “Now, we’re seeing some situations where payers are announcing to providers that they will not pay their claims if they don’t keep their information in directories updated,” he adds. “That’s a pretty severe way of doing things, but it does get their attention.”

The IDC report offers several recommendations for helping payers implement a successful directory and network strategy:

  • Categorize the provider data; determine data tiers and the costs of data quality.
  • Separate core directory data from operational data from “quality-would-be-nice-to-have” data.
  • For the directory data, adopt a collective non-competitive mindset. Is this data really a competitive advantage? Is it worth the cost of doing it alone?
  • Use a strong data model and data architecture, ensuring one system of record for all provider data.
  • Execute a multi-year comprehensive baseline, reactive and proactive approach to maintaining the provider data ecosystem.

“You’d be surprised how many companies do not have one—and only one—place where all provider data is housed. It’s usually all over the organization in claims, collections, contracting and provider performance systems,” says Rivkin. “You better have it in one place with one steward.”
When it comes to the accuracy of critical directory fields, he concludes that there are probably 100 to 200 fields that matter about a provider but, in terms of a directory, payers probably only need about 20 data fields.

(This article appears courtesy of our sister publication, Health Data Management)

“They’re not profound, but they better be accurate, such as name, contact, location, hours, specialties, languages spoken, gender, hospital and other affiliations, whether they’re in network, and whether they are accepting new patients,” he says.

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