September 2018

EHR Insider: The Consequences of Inaccurate Provider Directories
By Paul James
For The Record
Vol. 30 No. 8 P. 10

Provider directories often serve as the entrée into the health care system for members seeking services from an in-network clinician, yet these databases are fraught with errors. The inaccuracies are a burden for everyone—the patients who have trouble getting up-to-date information on which doctors they can see in network, the providers who have to constantly field requests from payers for data updates, and the health insurance personnel whose responsibility it is to make sure the data stay current.

Lack of comprehensive, integrated provider data is a major challenge for ensuring network adequacy, providing accurate and timely provider directories, and the operation of health insurance exchanges. Data must be culled from multiple sources that vary both in quality and accuracy, and there are few shared standards for the data definitions.

"This piecemeal system has serious cost implications," according to "Defining the Provider Data Dilemma," a 2016 report from the Council for Affordable Quality Healthcare. "One analysis estimated that commercial health plans and providers alone spend at least $2.1 billion annually to maintain their provider databases. It was estimated that 75% of those costs could be offset by integrating with an external source of truth, if such a source existed."

The root of the problem is that health plans often rely on legacy systems, and data are stored in multiple, disparate databases, lacking a single source of truth. A master data management solution can consolidate this disparate provider information and enable health plans to create a single, accurate view of each physician in their network—which will reduce costs for health plans while ensuring patients have access to the highest quality providers.

Value-Based Care Changes the Game
With the advent of value-based care payment models, many health plans offer members discounted narrow network products that limit enrollees' in-network choices to a specific set of contracted providers. Narrow networks are common in employer-benefit insurance plans, plans offered on the Affordable Care Act insurance exchange, and in Medicare Advantage plans.

If health plans can encourage members to visit providers who follow the value-based care model, it can result in better patient outcomes and, consequently, lower health care costs down the line. As a result, health plans have as much at stake as providers do in making a successful transition to value-based care.

Despite this reality, there is currently no unified process for updating provider directory information. Both insurers and providers have struggled to collect and maintain these data. "A critical issue for both health plans and consumers is the accuracy and completeness of provider directories," according to a report from American Health Insurance Plans. "Given the breadth and diversity of providers in health plans' networks and the frequency of changes, information can quickly become out of date. … With each health plan or medical group/independent practice association requesting updates on its own and each medical practice, hospital, and pharmacy working separately with Medicare Advantage plans, Medicaid plans, and private health plans, this process is time consuming and costly for health plans and providers alike."

A master data management solution can streamline this process, bringing together disparate provider data from various sources, matching and eliminating duplicates to create a single "golden view" of each provider on the list to ensure that members receive the most up-to-date provider information.

Incentive for Managing Provider Data
While accurate provider information is a shared responsibility of both providers and health plans, the health plans currently bear the full responsibility for the accuracy of these directories. Providers face recurring data confirmation requests from multiple health plans, which can be a significant administrative burden. Apart from contract nonrenewal, there is relatively little incentive for providers to keep their data up to date.

However, as of early 2018, there's at least one incentive for health plans to find a way to manage provider lists: the potential for steep fines. The Centers for Medicare & Medicaid Services (CMS) put new regulations into place this January that could result in fines against insurers of up to $25,000 per beneficiary for errors in Medicare Advantage plan directories. These penalties align with existing regulations that govern group plans. The Summary Plan Descriptions required under the Employee Retirement Income Security Act have long mandated that employees be able to access up-to-date provider directories, supported with fines for noncompliance.

Consumer expectations about the frequency with which provider directories should be updated have also changed significantly. The federal mandates have been supplemented by state legislators. Many states have now established regulations for how often such provider directories must be updated—ranging from annually (Connecticut) to monthly (Idaho) to, in some cases, even weekly (California).

The only way for payers to stay ahead of the curve with such stringent regulations is to employ a master data management system to ensure that such provider information remains current.

The Burden on Patients
In addition to the rising costs that payers face from poor data management of provider lists, the burden on patients is equally high. A survey from the American Medical Association found that "more than half of US physicians (52%) say they encounter patients every month with health insurance coverage issues due to inaccurate directories of in-network physicians."

In 2016, CMS began reviewing Medicare Advantage Organizations' (MAOs) provider directories in response to a beneficiary's complaint. CMS conducted its first review of provider location data in online directories in 2016, and its second round in 2016–2017. Each round included approximately one-third of all MAOs.

The results, which include the following, are alarming (second-round results are worse than the first):

• Combined, approximately one-half of the provider location data were incorrect.

• About one-half of an average MAO's provider directory data were in error.

• Provider directory inaccuracies resulted in significant access to care barriers in more than one-third to nearly one-half of locations.

A 2016 study in the journal Health Affairs illustrates the problem faced by consumers. Researchers "conducted a 'secret shopper' survey of 743 primary care providers from five of California's 19 insurance Marketplace pricing regions in the summer of 2015," with the aim of answering the following questions:

• No matter the nominal size of a network, can patients gain access to primary care services from providers of their choice in a timely manner?

• How does access compare with plans sold outside insurance Marketplaces?

Results were grim. "Our findings indicate that obtaining access to primary care providers was generally equally challenging both inside and outside insurance Marketplaces," study authors noted. "In less than 30% of cases were consumers able to schedule an appointment with an initially selected physician provider. Information about provider networks was often inaccurate. Problems accessing services for patients with acute conditions were particularly troubling."

Health plans must take responsibility for this poor data management issue and recognize that patient access to care and health outcomes and health plans' own revenue streams are two sides of the same coin. Master data management for provider directories allows for a win-win scenario.

— Paul James is chief technology officer at VisionWare.