Balancing compliance and member experience with a medical plan provider directory

Christie Helvey
July 27, 2021

How health plans can use data to retain and expand membership, all while staying compliant

Health plans have a lot to consider these days—member expectations are rising, competition for market share is heating up, and the Centers for Medicare and Medicaid Services (CMS) is adding more rules about the availability and use of data. With so many priorities to juggle, health plans need to find effective, cost-efficient ways to maximize value for members while staying on the right side of the rules.

That seems like a tall order and it is. Let’s take a look at why it’s so hard to keep up with medical plan provider data and what health plans can do to create a best-in-class medical plan provider directory.

Why are top-notch medical plan provider directories so hard to maintain?

Provider directories are essential tools for choosing a health plan for many potential and existing members. Health plans should know which providers are in their network, how to contact these providers, and where those providers practice. Unfortunately, it’s not so simple.

The challenge of keeping every bit of information up-to-date is mind-boggling. In a 2017 pilot, AHIP asked two different partners to contact practices and gather validated provider information. Between them, the two entities reached out to more than 150,000 physician practices. A mere 18 percent of practices completed the whole validation process. It took multiple contact attempts and dozens of questions to collect the necessary information.

More worryingly still, AHIP found that many practices didn’t understand why their health plans were contacting them. Providers didn’t understand the purpose of directories, didn’t know they were responsible for sharing updated information with their health plans and didn’t feel able to prioritize the process when they had so many other competing initiatives.

What happens if a medical plan provider directory isn’t up to scratch?

Health plans have two main things to worry about if their provider directories don’t make the grade: unhappy members and regulatory penalties.

With so many choices in the market, plans simply cannot afford to turn off consumers with missing, outdated, or incorrect provider information. Members expect to get answers when and where they need them, especially regarding their health.  

For many patients, a lack of information is more than just a superficial annoyance. For example, members with mobility issues or other disabilities have to know if physician offices are accessible and can accommodate their needs. But if the practice or the health plan incorrectly reports this information—or if there’s no data about accessibility whatsoever—patients might not be able to access the care they need to stay healthy.

CMS also intervenes when provider directories are subpar, which could mean hefty fines for health plans. Regulations allow CMS to fine Medicare Advantage health plans up to $25,000 per beneficiary for errors in provider directories. With that paltry 18 percent response rate from physician offices, that’s a whole lot of potential errors that could devastate a health plan’s bank accounts.

New patient access and data interoperability rules also complicate the picture. Under the new guidelines, health plans have to make specific data, including provider directories, available to members through APIs that work with third-party apps. Health plans that fail to meet the requirements risk potential penalties.

How can health plans improve provider data to offer better member experiences?

While achieving compliance and growing membership are high-stakes challenges, health plans don’t have to build and maintain provider directories alone. Partnerships are essential when it comes to provider data. There are data-driven tools available, like Ribbon, to help identify changes to provider information and deliver that data to members seamlessly and compliantly.

Instead of spending significant resources building an in-house team for provider outreach – and relying on overwhelmed practices to volunteer accurate information – health plans can work with a dedicated partner like Ribbon Health to make the hard work easy.

With sophisticated predictive analytics, thousands of proprietary data sources, and the people power to compile updates quickly, Ribbon Health can automate the process and ensure that members always get the right information when and where they need it. Accurate provider directory data is crucial for helping health plans stand out in the consumer marketplace while avoiding negative attention from regulators.    

Learn more about how Ribbon Health works with health plans to enhance consumer experiences, maintain compliance, and reduce burdens by developing a medical plan provider directory that really make the grade.

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