Provider directory software is an important tool for healthcare payers to implement. It allows a health insurance plan to publish an accurate and up-to-date list of all of the providers in their network.
Why is it important for a health plan to have provider directory software? Why do provider directories need to be accurate and current? What best practices should a health plan follow for managing their provider directories?
The Importance of Provider Directory Software
Health plans use provider directories for many different purposes.
Members use the provider directory to find providers that are in-network for their health plan. In the past, these directories might have been printed like a phone book. However, in modern times, there has been a shift to providing searchable directories online. Health plans may still offer printed directories on request. They may also offer downloadable directories in PDF format.
Additionally, other providers in the health plan’s network might use the directory to find in-network providers for referrals and authorizations.
The health plan’s staff may use the provider directory to support enrollment or referrals. Insurance sales agents will often use the health plan’s directory to show prospective members that their preferred doctors are in-network. This can help improve sales.
Provider Directories Must be Accurate & Up to Date
Government-funded health plans, like Medicare Advantage or Managed Medicaid, have regulations that require directories to be accurate and up-to-date.
Beyond that, regulations like the No Surprises Act put the financial burden for inaccurate provider directories back on the health plan. If a member sees that a provider is in-network in a directory and finds out later that the directory was incorrect, then the health plan must honor the in-network rates for services rendered.
If a prospective member enrolls in the plan based on faulty provider directory information, it can also lead to complaints or grievances. It may lead to voluntary disenrollment as well. This can cause a negative reaction in the marketplace. Insurance agents may be less willing to sell a health plan that has a history of publishing incorrect provider information.
It can be challenging to keep this information up to date. Providers can change employment frequently. A provider might leave a medical group that is in-network and go to work for a group that is not contracted with the plan. And medical groups will hire new providers frequently.
Best Practices for Managing Provider Directories
Health plans should follow some basic best practices for managing their provider directories.
First, define the data elements that you need to show members. This will include name and location information at a bare minimum. It also needs to include provider specialty information. You may also consider additional information like accessibility for disabled patients or an estimate of how quickly a patient can get an appointment.
Next, ensure that you have provider directory software designed specifically to manage your provider directory. Many health plans attempt to use their claims system to manage provider directory information.
This approach can lead to incorrect data being introduced into the directory. The data required to process a claim is very different from what should go in a directory. Keeping this data properly segmented is critical to provider directory accuracy.
You should consider engaging a User Experience designer to review your provider directory. You want to understand how members perform searches. Commit to improving the search experience.
Finally, establish a regular process for auditing your provider data to ensure it meets your high standards. Because this data changes so frequently, it is important to automate as much as you can. Consider supplementing audits with manual audits to ensure high quality.
If you’re looking for provider directory management software, consider Maven One. With a built-in rules engine for monitoring data quality per your rules, it gives you a custom-tailored solution in one stop.