With Deadlines Looming, Payers Need a Strategic Response to Provider Directory Data

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Provider directories are vital in helping patients and caregivers make well-informed decisions related to their health. For this reason, they must be accurate and accessible. But provider directories and the data that power them must evolve to meet the needs of both changing regulatory requirements and an increasingly digital member base.

The challenge of provider directory accuracy isn’t new. The 2018 Centers for Medicare & Medicaid Services (CMS) Online Provider Directory Review Report detailed common flaws, revealing 52 percent of physician listings in Medicare Advantage (MA) provider directory data contained at least one inaccuracy. The report was quick to point out that this has a ripple effect that can degrade the system as a whole: “Inaccurate provider directories can create a barrier to care and raise questions regarding the adequacy and validity of the MAO’s network as a whole.”

This report has prompted action on several fronts to address these issues, including the recently passed No Surprises Act and the still-looming Interoperability Act. While COVID-19 brought about changes and some delays which have bought payers a slightly larger window of opportunity to make these improvements, the bottom line is payers will need to take swift, strategic action to meet these challenging mandates.

Looking at the Big Picture

The trends and requirements shaping provider directories for the future:

  1. The Digital Health Revolution
     In the first quarter of 2020 alone, there was an explosion of Internet usage, with average broadband consumption increasing 47 percent. During this same quarter, the number of telehealth visits increased by 50 percent, compared with the same period in 2019. This sudden surge is not expected to go away: research from McKinsey found that 85 percent of healthcare executives predict lasting changes to consumer preferences. This means they not only will be expecting, but expecting better, more reliable healthcare data and options, including accurate and accessible provider directories. Expect them to also become more sophisticated in their demands.
  2. The Interoperability Rule
    Put into motion on March 9, 2020, the Interoperability Rule requires data to flow more transparently from payers to providers to patients. While the deadline for implementation was pushed back from January 1, 2021, the challenge to meet these new regulations, including the provider directory API, is now looming. The new deadline of July 2021 will quickly be upon all stakeholders.
  3. The No Surprises Act
    No one likes surprises—at least not when it comes to medical bills. After much disagreement about how to solve this problem, we’ve seen a significant attempt in the No Surprises Act, enacted by Congress on December 28, 2020. While this greater efficiency will serve members, it will also help increase consumer perception and satisfaction with payers. However, making the way to the finish line by the January 2022 deadline—including making necessary provider directory changes—will be challenging for payer who don’t have strategies in place or operations to support them. Be aware that for many payers, the Act mandates they will need to verify and update their provider directory database every 90 days. Payers now also must respond within one business day to requests from consumers about whether a provider or facility is in-network. These timelines create pressure for payers to increase the frequency of primary source verification of licensure and certification.

Staying Ahead of Requirements

Provider directory data are complex and incorporate multiple layers of information such as network tiers, contracting relationships, and multiple provider locations. At the same time, the data is continually needing to be updated—if a provider was accepting new patients last month, does it mean they’re still accepting them now? There isn’t necessarily a one-size-fits all solution for a payer.

Questions to Gauge Provider Data Preparedness

  • Do our current tools and processes allow us to meet the new database update frequency?
  • Is our compliance monitoring helping identify data inaccuracies on an ongoing basis?
  • How can provider engagement teams help verify provider data?
  • How can patients help keep directories accurate? 
  • How can we better engage and motivate providers to help keep their data accurate? One strategy is to identify providers who have verified their data, then advance them to the top of the directory.
  • Is this provider qualified to deliver this type of care to the member?

It’s time to get smarter about your provider network compliance monitoring.

The internal key to delivering provider directory accuracy and interoperability—and addressing these myriad new demands and deadlines—is accurate, transparent, accessible, interoperable provider network data.

If you need support meeting upcoming requirements, ProviderTrust can help by verifying the provider compliance data in your directories to ensure providers are eligible to participate in Medicare Advantage, Medicaid and other government LOBs. We also continue to provide ongoing insight into licensure and credential status, so your directories stay current.

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