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In the healthcare industry, provider data is crucial for maximizing operational efficiency, ensuring regulatory compliance, and informing patient decision-making.
Maintaining accurate and up-to-date provider information, however, remains a persistent and arduous challenge.
In this guide, Vālenz Health® explores the complexities that make provider data so difficult to maintain, the methodologies that can be used to cleanse and maintain data integrity, and the value these efforts can deliver to all stakeholders.
The Complexity of the Industry’s Provider Data Problem
Inaccuracies in provider data affect everything from claim processing and network adequacy to patient access and regulatory compliance. These errors create substantial administrative burdens and waste as organizations are forced to spend valuable time and resources verifying or correcting information.
In fact, the CAQH Index estimates the industry spends billions annually on manual provider data maintenance and has the potential to save $20 billion by moving from manual to automated workflows for certain processes.
Unfortunately, implementing widespread automation of data review is easier said than done, due to persistent industry-wide challenges:
- Data Inconsistency Across Sources: Provider information is often scattered across multiple systems, leading to missing or conflicting data points (such as National Provider Identifiers [NPIs], addresses, phone numbers, specialties, and network affiliations). This vast number of data sources and data types makes it difficult to maintain consistent, accurate records over time.
- High Rate of Change: New providers regularly join the industry, while existing providers often change locations, retire, or switch specialties. If not closely monitored, this quickly leads to outdated records. In fact, a 2021 review of online directories by the Centers for Medicare & Medicaid Services found that up to 48.39% of provider listings had at least one inaccuracy.
- Duplicate and Redundant Entries: Multiple NPI affiliations across professionals, facilities, and groups, combined with varying name formats, addresses, phone numbers and specialties, create redundancies and confusion, making it difficult to accurately track and manage provider-data relationships.
- Lack of Standardization: Different organizations format and store provider data differently, making industry-wide integration and validation challenging.
- Mergers and Acquisitions: Company and organizational consolidations can shift data ownership, forcing frequent revalidation and integration efforts.
While there are varying reasons for inaccurate provider data, the impact remains the same. When patients can’t locate the right provider data, they can’t make informed decisions about their healthcare choices.
Difficulty in finding in-network providers leads to wasted time, effort, and money — all of which creates a sense of frustration among members already confused by a complicated healthcare system.
Simplifying the Search for High-Value Healthcare: Five Ways to Ensure an Accurate Provider Data Library
Maintaining an accurate library of provider data is one of the best ways to connect members with high-value care — but, in the face of the abovementioned challenges, it can be easier said than done.
That said, employers have a responsibility to supply the up-to-date provider information employees need to seek specific care from high-quality, qualified reputable providers in their area.
To do so, employers and their healthcare partners (such as brokers, consultants, and third-party administrators [TPAs]) can consider partnering with an organization such as Valenz that implements the following strategies to maintain and optimize its provider data.
1. Automation for Data Consistency
Automating consistent, rule-based provider data tasks, such as standardized field validation, ensures regular systematic data cleaning and uniform formatting, simultaneously eliminating the introduction of disordered data.
By automating these repetitive steps, plan administrators can devote more time to nuanced, exception-based data challenges that demand human expertise.
2. Address Verification and Primary Location Determination
To ensure provider locations are accurate, administrators should cross-reference as many authoritative sources as possible to establish and confirm a provider’s primary practice location.
Regularly scheduled data validation like this can quickly identify any outdated or duplicate locations and flag them for immediate removal from member-facing and internal directories.
3. Provider Status Monitoring
The vast number of providers in a directory demands routine data checks against external sources to identify those that are retired, terminated, or otherwise inactive.
Regular audits can identify any discrepancies in network participation and continuously validate network data quality, provider counts, and geographic coverage.
4. Provider Specialty and Taxonomy Verification
Regular audits can also be used to validate, update, and maintain primary and secondary specialty data, which is of key importance when accurately classifying healthcare providers.
Any updates should be made in alignment with industry standards to ensure data consistency moving forward.
5. NPI and Facility Matching
In certain cases, multiple NPIs can end up tied to a single facility, causing duplicate directory data. Identifying and removing these instances can enhance comprehensive data mapping within the directory.
Linking any provider affiliations across different care settings also prevents data fragmentation and frustration with the user experience.
The Value of Accurate Provider Data
Validating and maintaining accurate provider data is about more than just preventing administrative waste. Ultimately, it’s about creating a better experience for the primary users of the database — health plan members searching for healthcare providers.
When patients can quickly find in-network providers with up-to-date contact information, they avoid the frustration of scheduling appointments with unavailable or relocated providers. Clear transparency in provider quality and cost empowers members to find the best fit for their needs, allowing them to make fully informed decisions about their healthcare.
Maintaining accurate provider data also leads to better representation in networks and search directories, giving patients a wider range of options to choose from. And, with accurate provider data, employers and healthcare insurers can better evaluate the adequacy of their provided network against their employee needs.
In short, a directory of accurate, detailed provider data is key to providing a seamless, transparent experience for members, improving their healthcare literacy, giving them greater control over their healthcare decisions, and preventing wasted time, energy, and costs for all involved.
Improve Your Provider Data Library Today
Accurate provider data is essential to the efficiency of healthcare operations, patient satisfaction, and regulatory compliance.
At Valenz, our teams deploy unique, advanced data validation techniques to proactively address these core challenges within the provider data ecosystem. In doing so, we ensure that providers, employers, and patients all benefit from a robust, reliable, and transparent provider data system that drives better decision-making and improved healthcare outcomes.
For more information about how Valenz is working to create smarter, better, faster healthcare for all, contact us below.