It’s no secret that provider data is difficult to manage for health plans. No matter what size your health plan is, you have probably experienced your fair share of these common provider data issues.
Let’s talk about the issues that appear most frequently that are relatively easy to solve with the right tools.
#1 – Providers With Invalid NPIs
Every provider needs to have a National Provider Identifier (NPI). This number needs to be used during the credentialing process as well as when submitting authorization requests or claims for payment.
The Centers for Medicare and Medicaid Services are responsible for issuing NPIs to providers. CMS maintains a national database called NPPES that is easily accessible to the public for validating the information on file for a provider.
While certain data elements within this database may not always be reliable or accurate, the status of the NPI itself should be validated routinely against the NPPES database. The reasons for this can vary, but they are all good reasons.
A provider may retire. Providers may be sanctioned by government entities. Providers may pass away. Incorrect NPIs may be provided during the provider enrollment process. A simple transposed number either by the provider representative or the health plan can render the NPI useless.
In these scenarios, their NPI may become deactivated. When this happens you want to ensure that all of your systems are updated appropriately. Retired providers who are no longer providing service to members should not be eligible for payment. They should also not appear in online provider directories or any future printed directories. Other providers should not be able to refer members to these providers.
Health plans need to make sure that these issues are acted upon promptly to prevent issues in member care coordination and delivery. Taking swift action will reduce the risk for fraudulent charges, such as a multi-provider practice continuing to bill claims using the provider’s NPI, whether intentionally or not.
Health plans should implement a series of upfront and ongoing edits on provider data to ensure accuracy. Upon entry of an NPI, an algorithm can be used to determine if the NPI meets the formatting requirements established by CMS. Once that edit is passed, a lookup should be performed against the NPPES to ensure the number exists in the database. Finally, all NPIs within a health plan’s database should be validated regularly to identify NPIs that have been deactivated and kick off appropriate workflows.
#2 – Invalid Provider Addresses
Having correct provider addresses is critical for many reasons. Provider network adequacy analysis uses address and specialty data to determine whether a health plan can adequately care for all of its members. Important correspondence may be sent to providers. This can include payment information and compliance notifications. Claim payments for services where fees may vary by region also need accurate location information for providers.
Many claims systems will use USPS Address validation software to confirm address information. These systems often focus on simply standardizing the address per USPS rules, not necessarily attempting corrections. This can lead to a significant amount of manual work. Provider Operations teams must subsequently research the correct addresses and perform manual corrections.
Savvy health plans will not only implement these validations upfront, but they will utilize smart technologies (like the Maven One Rules Engine) to perform auto-correction of addresses. These technologies will eliminate significant amounts of rework by leveraging a broader knowledge base and ruleset to perform data correction.
#3 – Missing Data Elements
Certain data elements on a provider record should be considered critical to a proper “gold” provider record. These include a provider’s name, address(es), specialty, contract effective dates, and participating status at a bare minimum. Many plans expand this to include gender to support member assignment. You may decide to use the provider’s date of birth in your network analysis. (For example, is our primary neurologist in a rural area rapidly approaching retirement age?)
Your Provider System of Record should enforce all of these rules upfront. The provider record should not be allowed to go in without passing all validations. The fields should be both present and correct. Specialties should be assigned from a configurable list. Addresses should be validated upon entry and before saving.
Many health plans may be operating on legacy systems that are inadequate for today’s needs. These systems take a lax approach to provider data intake, allowing critical fields to be empty or incorrect.
Health plans should implement rigorous data scrubbing practices to ensure that data is accurate initially and that it stays accurate over time. This includes a weekly or monthly automated review of all provider data on file. When incorrect data is identified, workflow processes should be used to perform any data corrections that cannot automatically be applied by the scrubbing software.
#4 – Incorrect Provider Contract Assignment
The assignment of a provider contract or fee schedule within a claims system dictates how the provider will be paid for claims that they submit. One of the most common reasons for inaccurate provider payment is incorrect contract assignment.
This can happen as a result of data entry errors or due to the lack of adequate controls within claims or provider data systems. A provider could also be assigned to an in-network contract when they should be out-of-network or vice versa. Or a provider may move from one medical group to another but the contract assignment change may slip through the cracks if workflows are not adequately followed.
Health plans should implement rules within their data scrubbing processes and systems to identify potentially incorrect provider contract assignments. In these cases, it is recommended that workflows are kicked off within the Provider Operations teams to research and correct the assignments within the claims and provider systems.
#5 – Provider Name Discrepancies
Providers may use various names to describe their business. For organizational providers, there is often a legal entity name and also a “Doing Business As” (dba) name. Members may be more familiar with the “dba” name whereas the legal entity name needs to appear on IRS reporting (1099s) to comply with US Treasury regulations and avoid costly fines.
For individual providers, their names may change as the result of a marriage or divorce. Additionally, most claims and provider systems are incapable of detecting the first name versus a last name. This can often result in first names being put in the last name field and vice versa.
All of these issues can be a challenge to manage. You may need to keep track of a “vendor” record for legal entities where you can store the IRS-sanctioned name for tax reporting purposes. At the same time, you may want to maintain a provider record using a dba name that your members will be familiar with. This is likely the name that appears on signage outside the provider’s office.
Health plans should establish rules for validating provider names. The name that the provider gives may be determined to be the correct name for provider directories. You may decide to use the IRS name or one of the names from the NPPES database as the name of record for the provider. Your rules should be granular enough to make exceptions based on the type of provider or the specific provider. These rules should be configured into the health plan’s data scrubbing processes to ensure accuracy and consistency in all downstream processes and systems.
Easily Address Common Provider Data Issues
These are only a few of the most common provider data issues. Many of these have fairly straightforward solutions, but they
The Maven One Rules Engine for provider data management allows health plans to configure rules to address all of these common provider data issues and more. Coupled with the Maven One Streamline engine for workflow management, health plans have a powerful suite of tools at their disposal that can be implemented in as little as 30 days. With rapid results and configurable rules and workflows, health plans can address these challenges as painlessly as possible and keep their focus on ensuring overall quality within their provider network while providing exceptional provider and member experiences.