The focus on provider directory quality has increased rapidly at both the state and federal level. In 2015, California fined Blue Shield of California and Anthem Blue Cross of California $350,000 and $250,000, respectively, for inaccurate directories. Since then, CMS, Medicaid agencies, and many states have adopted explicit directory requirements that include oversight of data quality. While CMS has yet to levy any fines for inaccurate provider directories, a 2016 CMS rule proclaimed that fines for inaccurate directories would be levied against MAOs at the rate of $25,000 per impacted beneficiary. In addition, as part of health plan accreditation, MAOs are also required to comply with provider directory requirements from organizations such as the National Committee for Quality Assurance (NCQA).
As regulatory oversight continues to persist, the need for an effective PDM strategy has become increasingly important. A successful PDM strategy must address several common challenges:
1. Lack of Alignment with the Provider Directory Use Case: Health plan provider data management systems are often not aligned to regularly serve directory quality. The inaccuracy of online and print directories, and the resulting impact on patients, spurred a response from some regulators to solidify new requirements for directories. The regulations required alignment with new data definitions as well as regular updates to both paper directories and online directories within thirty (30) days of when a plan receives updates regarding a provider’s information. As a result, health plans now must establish the ability to collect, manage, and distribute data changes at near real-time speed.
2. Lack of Provider Engagement in the Directory Use Case: Providers may not understand the urgency and value behind provider directory accuracy. While plans are now required by Medicare to conduct outreach to providers on a quarterly basis for updates to directory information, providers may not relate to the reasoning behind the increased urgency. With numerous data requests coming from multiple plans to support credentialing, care quality, claims, and other core processes, providers are forced to prioritize their responses and timeliness is often impacted. The value of accurate provider directories must be successfully translated to providers to achieve improved provider engagement.
3. A Need to Realize Incremental Improvements: While new directory requirements impact multiple data elements, the areas where data quality suffers the most are well known, including practice locations and a provider’s panel status. Regulators have focused on these areas because they highly impact a patient’s access to care, and incremental improvements in these areas can help produce a more accurate directory. Plans have an opportunity to define a roadmap that prioritizes the implementation of solutions most impactful to improving directory accuracy.
In order to solve these challenges, health plans must develop an enterprise PDM strategy that encompasses stakeholder alignment, effective provider engagement, infrastructure integration, and streamlined data collection processes.
- Stakeholder Alignment: Alignment across internal stakeholders such as compliance, enrollment, credentialing, provider relations, and network management teams is imperative to integrate cross-functional needs and priorities. This can also begin to mitigate and reconcile low quality provider data originating from different sources that support the provider directory function.
- Effective Provider Engagement: Plans are burdened by the need to demonstrate the value of high-quality directories to providers to engage them effectively, receive timely data, and to avoid provider abrasion. A targeted communication plan can help providers understand the benefits to themselves as well as their patients. Once providers understand the benefits of maintaining an accurate directory, mechanisms that make it easy for providers to update their information should be available. The above measures should encourage provider engagement while making it easy for them to submit timely, accurate demographic updates.
- Infrastructure Integration: Plans should perform a full inventory of all the systems being used to support provider data management, including points of input and output, and assess the level of integration across systems to pinpoint the areas where low quality data may enter or linger, or where high quality data is being overwritten. This will allow plans opportunities to identify and develop approaches to resolve existing gaps while gaining new efficiencies as the data infrastructure is integrated.
- Streamline Data Collection Processes: To maintain the integrity of system-wide provider data, plans must also ensure that the data sources from which data is collected provides them with high quality, timely information based on the right definition for the directory. Costly and cumbersome manual processes such as phone calls to providers are unreliable and may contribute to provider abrasion. To combat such issues, plans should explore opportunities to implement tools such as Artificial Intelligence to score and validate provider data, which could eliminate the need to contact providers. This allows plans to be more targeted in only reaching out to providers when necessary, e.g., for audit purposes, as well as increases intelligence in leveraging provider data from other sources.
Continued oversight by CMS and other regulatory bodies, as well as ongoing provider data management challenges, present an opportunity for health plans to establish the path forward to improve directory data quality and support overarching business needs. Plans should be proactive in developing and implementing enterprise-level PDM strategies that will allow them to collect, maintain, and leverage high quality provider data.
At crankfrog, we understand how to create a successful PDM strategy from the ground up. We can provide assessments that will give organizations insight into their efficiencies and pain points, and begin to address those pain points through comprehensive stakeholder engagement and road mapping. We recognize that not all organizations are the same or have the same capabilities when it comes to provider data management. The industry’s continued focus on directory quality emphasizes the need for health plans to assess their current state and to strengthen existing PDM strategies.
 CMS (2018). Online Provider Directory Review Report. Accessed. May 9, 2019: https://www.cms.gov/Medicare/Health-Plans/ManagedCareMarketing/Downloads/Provider_Directory_Review_Industry_Report_Round_3_11-28-2018.pdf
 Terhune, Chad (2015). California Regulator Slams Health Insurers Over Faulty Doctor Lists. Accessed May 6, 2019 from: https://khn.org/news/california-regulator-slams-health-insurers-over-faulty-doctor-lists/.
 Adelberg, Michael and Michelle Strollo (2017). From Machine-Readable Provider Directories, A Preview Of A Revolution. Accessed on May 3, 2019 from: https://www.healthaffairs.org/do/10.1377/hblog20170227.058937/full/; For example laws, see: CO BOI Bulletin 4.90 – 4.93 (2019), GA § 33-20C et al (2019), MD § 31.10.44 (2019).
Jaffe, Susan (2015). Obamacare, Private Medicare Plans Must Keep Updated Doctor Directories In 2016. Accessed May 1, 2019 from: https://khn.org/news/health-exchange-medicare-advantage-plans-must-keep-updated-doctor-directories-in-2016/
 Council for Affordable Quality Healthcare (2019). CAQH Develops Artificial Intelligence to Improve Provider Directory Accuracy. Accessed on May 13, 2019: https://www.caqh.org/about/press-release/caqh-develops-artificial-intelligence-improve-provider-directory-accuracy