Data practices and consolidation of fragmented data would bring significant benefits to payers, which are under increasing pressure to make better the information they present to consumers, in accordance to a recent report from IDC Health.
Customers hope payers to make available quality provider data, contends Jeff Rivkin, research director for payer IT strategies at IDC Health Insights. However, he discusses that payer directories sustain to be inaccurate, out of date, and generally hard to use.
By issuing the directories online, health insurance companies expected to solve some of these problems. Nevertheless, in accordance to Rivkin, it only served to highlight for consumers the poor quality of directory data. Because directory data tends to be incorrect, members are likely to be hit with out-of-network charges; patients are not able to find contributors that accept new patients; and overall consumer satisfaction is declining.
The IDC report cites 1 vendor who contended that in its survey of 200 U.S. health plans, payers were only 55 to 70% correct on critical directory fields.
Rivkin makes the case that incorrect, inadequate provider information is no longer acceptable in this increasingly litigious, regulated, consumer-focused and competitive setting in which payers is operating. Consequently, he considers health insurers should be prepared for increased network adequacy and directory quality audits from the Centers for Medicare and Medicaid Services. Furthermore, California, Maryland, New Jersey, Vermont, and Washington, D.C., now require proactive verification of provider data.
“The fines are coming; the audits are happening,” Rivkin alerts.
An adequate network involves providers that can address a variation of patient healthcare needs and deliver the services that the plan covers under its benefits package, Rivkin notes. Particularly, he asserts that “network adequacy" refers to a health plan’s ability to deliver benefits promised by offering the reasonable access to a sufficient number of in-network primary care and specialty physicians, as well as all healthcare services included under the terms of the contract.
Consequently, from the perspective of insurers, maintaining the precision of their directories is imperative for their own success, Rivkin contends.
But payers are not totally to blame. Provider information is constantly changing and therefore very difficult to keep up to date. The IDC report notes that 2% of provider demographics change each month; 20 to 30% of doctors change affiliations each year; 5% of doctors have a status change each year—they lose their license, retire, die or are sanctioned.
Rivkin analyzes that because regulations are increasingly targeted at payers, insurers are genuinely putting pressure on contributors, who are the source of the bad data. “Now, we are seeing some situations where payers are declaring to providers that they will not pay their claims if they do not keep their information in directories updated,” he adds. “That is a pretty severe way of doing things, but it does get their attention.”
The IDC report gives various recommendations for assisting payers implement a successful directory and network strategy:
- Categorize the provider information; determine data tiers and the prices of data quality. Separate core directory data from operational data from “quality-would-be-nice-to-have” data.
- For the directory data, adopt a collective non-competitive mindset. Is this data really a competitive advantage? Is it worth the cost of doing it alone?
- Use powerful data model and data architecture, making sure that one system of record for all provider data.
- Execute a multi-year comprehensive baseline, reactive and proactive access to maintaining the provider information ecosystem
No comments:
Post a Comment