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Claims Data Makes Provider Directories More Accurate

Posted by Laura McMullen on Thu, Jan 21, 2016

“About 70% of plans sold on the exchanges in 2014 featured a limited network, and their premiums were up to 17% cheaper than plans with broader networks, according to a study by consulting firm McKinsey & Co.”, reported Modern Healthcare in March 2015. In response to consumer complaints about narrow networks, network adequacy regulations set criteria for distance to providers; the quantity of providers in a network; and the inclusion of essential community providers in a geographic area and, beginning January 2016, fines for inaccurate data.

Accurate provider directories are a problem for all networks. Providers retire, sell their practices, change jobs, and die, just like everyone else. It’s difficult to stay on top of this information, especially if you have several networks and/or network partners. The credentialing process, where provider credentials are reviewed at least once every three years to evaluate their practice histories and qualifications, and self-reporting are the primary methods network managers use to update their records. A 2014 study published in the Journal of the American Medical Association Dermatology found that these methods aren’t working:

  • Among 4,754 total dermatologist listings in Medicare Advantage networks in 12 US metropolitan areas, 45.5% were duplicates in the same plan directory.
  • Less than half (48.9%) of the unique physician listings were reachable, accepted the listed plan, and offered an appointment.

The Department of Health and Human Services’ Office of the Inspector General found similar results when looking at Medicaid networks in 2014. When they surveyed 1,800 primary care providers and specialists, “35 percent could not be found at the location listed by the plan, another 8 percent were at the location but said that they were not participating in the plan, and an additional 8 percent were not accepting new patients.”

Some experts suggest improving the accuracy of provider directories by including only providers to whom you’ve paid claims within 12 months. “Since 2013, New Jersey health plans must attempt to contact any provider who hasn't filed a claim in 12 months. If a provider fails to respond in 30 days, the insurers must remove that listing. Since then, ‘the number of complaints has gone down,’ says Larry Downs, CEO of the Medical Society of New Jersey,” in “Insurers Race to Avoid New Fines” on nasdaq.com.

Overstated access has been a problem in dental PPO provider directories for several years; access points are growing twice as fast as unique providers and unique locations.

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We’ve seen success using claims to verify locations where providers are practicing in our dental network analyses. In general, we find that about 75% of dental access points can be validated through claims analysis. Demonstrating clean data vs. your competitors is a definite advantage when selling your network to clients and brokers and also helps focus recruiting efforts, saving time and money. Learn more about our approach in our whitepaper Are Dental Provider Directories Overstated?

What steps are you taking to ensure accurate provider directories? How do you figure out which providers are really available in your competitors’ directories?

Tags: narrow networks, provider networks, dental PPO networks, medicare advantage, provider directories, claims data

 

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