Provider data management is usually discussed from the provider perspective: the busy staff, the needless paperwork amid a pandemic, the faxing, emailing and uploading of data. In these scenarios, the health plans are often painted as the villains for their bureaucratic processes and unique requirements. But the reality is that health plans aren’t totally to blame.
Payers and providers share a common goal: to provide the best quality care for their patients. The amount of data, including basic provider profile information, that need to be shared to reach that goal has grown significantly over the years and does not show any indication of trending downwards.
Let’s face it; payers struggle to streamline the millions of data points flying in, out and through their systems daily. Each practice, group and hospital system a payer works with has a large subset of data tied to clinicians and the provider organization. Each nugget is valuable and needed to both successfully treat patients and compensate the provider while maintaining quality initiatives. But when something goes wrong with provider data management, the finger is often pointed at the payers.
Payer Challenges with Provider Data Management
For payers, it’s a constant revolving door to keep provider information accurate and up to date. According to a 2016 IDC Health Insights report, 2% of provider demographics change each month, and 20%-30% percent of physicians have employment updates each year. With expectations that COVID will accelerate the already-abundant healthcare mergers, maintaining data in a timely manner is only becoming more important.
While reviewing on a 90-day cycle is the standard, it often isn’t frequent enough. By the time an update is passed through an intermediary, processed on the payer side and applied to the correct profiles, it could already be out of date again.
Additionally, health plans continuously have difficulties engaging with providers for a multitude of reasons. Providers and their staff are busy, plain and simple. Office staff have other responsibilities and often deprioritize these tasks. This is especially true while practices continue to adapt to the constantly changing protocols that the COVID-19 pandemic has created. It can also be difficult to get providers to comply with rules or adapt the habit of sending updated information. Simply reminding providers is easier said than done, as states put varying limitations on payers concerning how often they can outreach to providers. That means collecting and disseminating more information with fewer touchpoints.
Not having the right data is costly for both payers and providers. Poor provider data management from both parties leads to frustration on the patient side when directories are inaccurate. A patient may have spent a significant amount of time finding a provider in their network that meets their needs, only to find out the provider moved offices six months prior. Providers can lose revenue from missed appointments, and payers can face hefty fines. As of 2016, CMS regulations permit the agency to fine health plans up to $25,000 per Medicare beneficiary for errors in Medicare Advantage plan directories, and up to $100 per beneficiary for mistakes in plans sold on the Affordable Care Act exchanges.
How to Ease the Burden With Providers
Keeping up with provider data management can be tedious and time-consuming, but it is for these types of tasks that automation exists. Payer portals have improved the “electronic” piece of electronic data exchange, but without a single source of truth that automates the application of data across organizations, payers and providers are destined to refill, retype and reprocess data over and over. Payers should work with clearinghouses and other intermediaries, or even their own internal teams, to institute solutions that make it easy for providers to update data once to automatically be applied to various forms and paperwork.
With automation, there will be fewer claims denied for a singular data point mismatch, faster onboarding for new clinicians, and fewer headaches for avoidable problems. Less administrative work for the payers and quicker payment is a winning combination for payers, providers, and everyone in between.
About Eric Demers
Eric Demers is the CEO of Madaket Health, steering the team as it becomes the neutral hub and single source of truth for provider data exchange. Eric has a keen eye for applying technology solutions to age-old problems in healthcare to help create efficiency and scale.
