Leveraging automation in healthcare to fix the provider directory problem

Ribbon Team
May 11, 2021

How can health plans use automation in healthcare to keep members informed and maintain CMS compliance?

Healthcare is full of constantly moving pieces. From the fast-paced world of patient care to the complexities of managing millions of health plan members, nothing in this industry ever stands still. For Medicaid and Medicare plans, keeping up with nonstop changes to their networks is one of the biggest challenges out there.  

Members rely on provider directories to learn about their healthcare options. They need to know which clinicians are in-network, which are accepting new patients, and their location. Yet, health plans are often perennially behind the eight ball as they struggle with the never-ending updates of a long list of provider data elements.

Fortunately, with the advent of automation in healthcare, plans can surmount the provider directory problem. With artificial intelligence (AI) and machine learning, automating provider directory updates can play a crucial role in helping health plans maintain compliance and offer best-in-class experiences for their members.

Increasing regulatory scrutiny on provider directories

Health plans use provider directories to ensure that members get to the right provider for their needs as quickly and efficiently as possible, which helps raise member satisfaction and avoid unnecessary spending on duplicate or improper care. But recently, provider directories have landed some health plans in hot water.

In 2016, the Centers for Medicare and Medicaid Services (CMS) started monitoring Medicare Advantage Organizations’ provider directories and fining those with chronically sub-par data. It can cost a plan as much as $25,000 per beneficiary per day for errors in Medicare Advantage plan directories.

State legislators have followed suit by establishing regulations for how often plans should update provider directories and penalties for noncompliance. As of 2016, 36 states have mandates for varying levels of provider data updates, ranging from annually to monthly to, in some cases, even weekly.

For example, California requires health plans to reach out to all contracted providers quarterly to update over 100 data elements. When informed of any changes, plans must update their online provider directory data at least weekly. Those who don’t comply are on the hook for out-of-network healthcare services due to incorrect provider data in their directories.

Navigating the myriad of federal and state regulations can be disorienting for health plans, particularly plans with a presence in multiple state markets.

Keeping up with provider data

Just like members, providers are always on the move. Up to 30 percent of providers will switch affiliations in any 12-month period. Another 8 percent will require changes to their demographic information or licensing status for other reasons. As a result of these rapid-fire demands, inaccuracies in health plan provider directories are shockingly common.  

A CMS review from 2018 found that 49 percent of Medicare Advantage provider directory locations had at least one inaccuracy, with error rates of up to 93 percent in some of the plans scrutinized by the agency.

The inaccuracies included:

  • Incorrect phone numbers
  • Providers who did not practice at the given location
  • Outdated information about whether the provider was accepting new patients

In and of itself, inaccurate provider data is a costly problem. Factor in its downstream effect on members, and the impact becomes much more harrowing—CMS points out that these errors have a high risk of inevitably blocking access to care.

The incentive to keep provider directories up to date is high, but health plans are finding that maintaining provider information is a significant challenge. Manually sourcing and verifying updates can often take weeks or months, and by the time directories are updated, the information could be out of date again.

How can health plans ease the administrative burden of keeping the provider directory up to date?

Automation in healthcare to build a better provider directory

Automation in healthcare is becoming more commonplace as more organizations find that it can lift the burden of tedious, time-consuming tasks. Provider data is the perfect use case for this new wave of innovation. Instead of manually sourcing and validating provider information, health plans can tap into the latest healthcare technology, like AI and machine learning, to parse through the noise.

For example, instead of depending on in-network providers to send updated information or health system rosters, health plans can get ahead of the curve by implementing AI-powered tools that can regularly scrape a variety of sources to pull different provider data elements and use machine learning to validate that the information is correct.

With reliable data and cutting-edge analytics to support real-time updates, plans can save time, ensure compliance, and offer better experiences to their members.

How Ribbon Can Help

Rather than building a solution in-house, health plans are turning to Ribbon Health, a highly accurate provider data resource, delivered through flexible and easy to implement APIs. With Ribbon, health plans can augment their data assets, while strengthening data quality and their provider search experience.

We’ve built our solutions to support member-friendly search, and we deliver a fast, intuitive experience, at any scale. Learn more about how Ribbon Health works with health plans to transform automation in healthcare.

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