High-quality provider data: why it’s a key advantage for health plan network teams

Stephanie St. Thomas
October 14, 2020

With rising healthcare expenses, cost-conscious employers, and a challenging ACA marketplace, health plan network and provider contracting teams face a higher level of pressure than ever before.

They need to quickly respond to changing markets, creating and adapting plans that promote high-quality, high-value care.

At Ribbon Health, we frequently hear from health plans about two frequent challenges:

  • Unreliable, contradictory, and difficult-to-maintain provider data within their organization
  • A lack of visibility on providers outside of the health plan’s existing contracts and networks
Provider data problems

Take a walk through the headquarters of a typical health plan, and you’ll find that many teams store and manage their own sets of provider data. That leads to data that’s siloed and difficult to update across the organization. The situation gets more complicated as teams bring on their own individual tools for network design, provider data management, customer relationship management (CRM), and more.

While siloed data tends to become inconsistent over time as individual teams make updates, there are persistent industry-wide issues with the sources of provider data. A clear example of this is the inaccuracy and inconsistency across the National Plan and Provider Enumeration System (NPPES), compiled by the Centers for Medicare & Medicaid Services (CMS). CMS audits show this data is 48% inaccurate.

A barrier to business growth

Inaccurate provider data means that provider network and contracting teams are at a disadvantage. Both need comprehensive information about provider organizations of all sizes. Gaps in provider information also make it difficult for health plans to understand network adequacy infringements and build compelling provider networks.

Inadequate provider data can also jeopardize consumer satisfaction with a health plan, making consumers and their employers unlikely to use health plan tools to find a doctor.

Health plan teams have had to endure years of difficulties with provider data

What if it didn’t have to be this way?

What if health plans could plug into a national reference database of highly accurate provider data? By coupling this external database with the organization’s own data resources, through machine learning, health plans would continue to build their own market information, with an immediate way to validate all data.

This comprehensive, high-quality data would provide a clearer sense of market dynamics, both from field knowledge gained by sales and contract teams, and from nationally-validated data sources.

Reliable and nuanced provider data could inform network design

Health plans would be well-equipped to benchmark providers who are high-value (competitive cost, high quality care) and design value-driven, high-performance networks.

Network design would become simpler if team members could access in-depth information on providers’ areas of specialization, such as experience in conducting a specific type of surgery. Quality indicators would add another level of insight.

Improved provider data would be an organization-wide resource

Rather than maintaining siloed data, teams throughout the organization could connect to a consistent, up-to-date provider data resource.

Ribbon Health gives network teams crucial advantages

Ribbon Health provides highly accurate provider data to support leading health plans and digital innovators. We compile provider data from thousands of sources and validate it with machine learning, so we can clearly convey the relationships between individual providers, their practice locations, their health system affiliations, and their health plan networks.

Then, we work in partnership with our customers to append and augment their existing data. Our flexible, modern architecture makes it straightforward for organizations to provide consistent, comprehensive provider data across their organization

We support our health plan customers’ goals, helping them to build the best data for growth, member engagement, and a digital front door that consumers trust.

Learn more about how Ribbon Health supports health plan network teams and helps them achieve their goals.

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