Staying compliant across your provider networks shouldn’t be complex.
Regulatory complexity and disparate provider data make compliance hard to achieve.
Provider data across your health plan is fragmented.
Ongoing compliance across your providers is becoming increasingly complex. We’ll design a monitoring solution that incorporates a holistic view of compliance across your providers to include exclusions, sanctions, NPI status, licensure status, DEA registration, and providers’ historical data.
Customizing monitoring requirements by a line of business is tedious.
Managing various state and federal billing compliance requirements across each provider network and each line of business is complex, time-consuming, and risky. We design tailored monitoring solutions based on your custom requirements to ensure billing accuracy and compliance across each business line and provider network.
Maintaining provider directory accuracy is a constant challenge.
Recent audits confirm that maintaining an accurate provider directory is becoming increasingly difficult. The latest 3-year audit by CMS found nearly 50% of providers across MA plans had at least one inaccuracy. We leverage our enhanced provider data to establish a monitoring baseline for your directory that includes ongoing NPI, licensure, sanction, and exclusion status.
Gaps and inconsistencies in primary source data increase compliance risk.
It’s no secret that managing documentation from various primary sources is disparate, challenging, and resource intensive. We enhance primary source data to catch exclusions other solutions never find, such as name changes, changing states and switching addresses, new or former licenses issued, or DBA entity incorporations for excluded individuals.
Say hello to Dash.
Our smarter data fills in the gaps at the primary source to complete your provider record.
Top Seven Monitoring Challenges for Health Plans
Smart, integrated monitoring is the key to mitigating risk within provider networks. As health plans transition to ongoing eligibility monitoring, these are the top challenges they face.
Resources to help Provider Operations teams grow & succeed.
PECOS plays a critical role in facilitating communication and data accuracy between providers and CMS. It powers several datasets indicating providers' statuses and standing with CMS.
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The Interoperability Rule, currently slated to go into effect in 2021, impacts provider network data for health plans in addition to significant implications for patient health data requirements.