Provider directories are vital to maintaining a smooth and accurate workflow for contracting, credentialing, payments, claims information, and more. Online directories are also very challenging to keep up-to-date given the constantly changing nature of provider networks and where those providers operate.  

Unfortunately, many organizations are having trouble displaying accurate provider profiles resulting in many issues such as – higher compliance risk, incorrect billing, high recoupment costs, and general frustration over quality standards for beneficiaries and providers. In this post, we’ll take a look at some of the challenges of maintaining provider directories and how to utilize an NPI to fill in the gaps of provider data.

What are Provider Directories?

Provider network directories are an important reference point that plan enrollees utilize to select and contact their physicians and other contracted providers who deliver medical care.

Members rely on these registries to make informed decisions regarding their healthcare options. Likewise, providers benefit from having their information as updated as possible to provide transparency into which networks they are participating in, and to show if they are accepting new patients.

CMS Finds Inaccuracies in Provider Directories

When provider information is inaccurate, it can create many problems with efficiency and provider network relations as they relate to particular health plans and member networks. The Centers for Medicare and Medicaid Services (CMS) has identified issues related to directories in a variety of reviews. The most recent CMS Online Provider Directory Review revealed some concerning statistics related to how provider information was incorrect or misrepresented. A few common errors that occurred were the following:

  • Incorrect phone numbers were presented
  • The address of the provider was different than listed on the directory
  • Some providers were not seeing new patients, even though the directory said otherwise

While some of the above issues may seem like small inconveniences, they can pose many billing or member problems, as well as create a general lack of confidence in the entire directory system and health plans involved.

In 2016, CMS launched a series of audits in response to beneficiaries complaints aimed at reviewing directory accuracy for Medicare Advantage Organizations (MAOs). Now, these audits run on a 3-year cycle with ⅓ of MAO’s being reviewed each year. Recently, audits have found that nearly 50% of locations have deficiencies related to inaccurate information. The most common deficiencies are related to providers being listed incorrectly by location within the directory.

CMS has stated that a centralized repository of provider data would be beneficial to ensuring consistency but they’ve also acknowledged that it will take time, effort, and collaboration across the industry to get there. In the short-term, CMS is suggesting organizations find other means and processes to work on directory accuracy.

Using an NPI to Improve Provider Directories

Within a clunky and somewhat outdated system of updating provider information across U.S. healthcare, third-parties help control and automate the assembly of disparate data. Many times, these companies are looking to finding common denominators between all of this information, and one such unique data point is the National Provider Identifier (NPI).  

NPI Healthcare

 

By utilizing an NPI as an anchor for a provider’s information in your provider management system, you can have confidence in the fact that it will be the most accurate in regards to that provider’s name, practice location, and specialty. This accuracy assists beneficiaries when they’re searching for a provider as well as reduces provider information errors in the claims process.

Choosing a Solution for Provider Directory Accuracy

To solve for inefficiencies and an error-prone system for accurate provider information, many healthcare organizations choose to contract with a data solutions partner to help solve their problems. With an NPI being a unique identifier that is consistent across the industry, ProviderTrust is a firm believer in using it as the anchor for your provider network management system. Once the NPI is at the center of the provider’s record, it can be used as the basis for credentialing, exclusion monitoring, provider information updates, shared data, etc.  

Our team is ecstatic to continue to push healthcare forward with innovation and by curating the right data to build accurate provider profiles for increased quality. We have built the tools to help establish data confidence for a proactive approach to improving provider relations and delivering the correct information for members and industry professionals.

If we’re going to improve healthcare by lowering costs, increasing accessibility, and improving outcomes, it’s going to have to start with changing our thinking about data and how we can work together across the industry. Starting with the NPI is a small way to start impacting those changes.


To learn more about how we utilize an NPI to establish a more trustworthy database, feel free to reach out. Please contact us via email or call!


Check out our latest resources!

ProviderTrust PassPort Healthcare License Monitoring


Written by Leah Everson

ProviderTrust Health Plan Segment Leader, leverson@providertrust.com

Leah is a Business Development professional with over 10 years of experience in the healthcare industry. She is dedicated to helping health plans and managed care organizations achieve success and improve their operations. 

 Connect with Leah on LinkedIn