The challenge of streamlining provider data management solutions

Stephanie Diaz
March 9, 2021

Data is the solution to — and the cause of — healthcare’s biggest problems

Provider data management solutions are at the heart of the healthcare industry. But as it stands, the process for collecting and maintaining provider data is a significant roadblock to unlocking the full potential of the healthcare ecosystem. The lack of a single source of truth, internal accountability structures, and industry-wide data standards contribute to the problem.

On the surface, this seems like a problem that could be solved easily, right? After all, the healthcare industry spends an estimated $2.1 billion annually to maintain provider databases, so accurate and comprehensive provider data is clearly an industry-wide priority.

Then why is the system still so broken? And what can we do to fix it? Let’s look at a couple of reasons why provider data remains fractured and recent efforts to drive streamlined provider data management solutions.

A sea of data, but no star to steer by

When collected and maintained correctly, provider data management solutions can unlock better health outcomes, improve patient experiences, increase cost-savings, and more. Even with all this at stake, we’re somehow still in the wild west of provider data.

The current process for obtaining provider data is incredibly piecemeal, varied across providers, and is often time-consuming. It involves sifting through literally thousands of resources in different locations (spreadsheets, commercial and government databases, etc.), and before that data is actionable, providers have to find a way to validate and standardize these data points at scale.

To get an idea of just how big of a mess this creates, consider the following from a recent white paper by the Council for Affordable Quality Healthcare:

[A] typical practice holds, on average, 12 managed care contracts with health plans at any given time, and each health plan requires approximately 140 different provider data elements for contract management. A practice with five providers and the average number of managed care contracts must manage 8,400 data points. Further, each health plan may require their contracted providers to report different data sets in different formats at different frequencies.

Collecting, validating, and standardizing so many different data points takes time away from frontline clinical care and is a substantial administrative burden. Not only that but maintaining the data and ensuring quality control is arduous when there is a lack of industry-wide standards. The ultimate impact goes well beyond just the operational inefficiencies themselves: When data isn’t standardized or, in many cases, even accurate to begin with, patients suffer most.

More than half of physicians say their patients faced coverage issues at least monthly due to inaccuracies in provider directories. Those issues range from being unable to get accurate practice addresses, contact numbers, and new patient acceptance. Further, a Centers for Medicare and Medicaid Services (CMS) audit of Medicare Advantage plan directories found that the data inaccuracies are most likely to interfere with access to care were found in almost half of provider locations.

In short, many providers are risking valuable time with patients and undergoing other operational and financial costs by spending an excessive amount of time collecting and managing provider data. But there’s another issue at play here that’s equally to blame for problematic provider data.

Too many cooks in the data kitchen

Almost every part of a provider practice — IT, care coordination, billing, and coding — interacts with provider data. Each of these departments uses distinct provider data points and the way they use them also differs. The only problem is that, more often than not, there is an evident lack of ownership. A recent survey showed that nearly two-thirds of survey respondents (73 percent) reported job roles directly tied to governing provider data. Meaning, not only is there no industry-wide source of truth, but there is a lack of one internally at many provider organizations.

The consequences have severe implications for data governance — ranging from nomenclature issues — one department calls a data point by a different name than the others — to problems with accuracy. Human error also comes into play when various staff members manually enter and update data with no overarching governance body.

Who’s using the correct data? Which department is using outdated or just plain wrong information? And most importantly, who is responsible for ensuring accurate provider data? Without accountability structures in place, efforts to improve the accuracy and effectiveness of provider data will continue to falter.

And once again, patients suffer the brunt of the consequences. Something as simple as a typo or a value entered can mean costs patients get billed incorrectly, are referred to a specialist that is no longer practicing, or are denied care — or even receive the wrong care.

The future of reliable provider data management solutions

There is some good news over the horizon: There’s a growing call for increased (or at least, any) industry-wide standards at the state and federal level. The New York State Department of Health, for example, implemented standards for all provider data that’s submitted for Medicaid, Marketplace, and commercial health plan network review. Each plan submits data in the same format, and all data points undergo the same review process for all products offered through provider networks in the state. More states may follow suit sooner rather than later. Another recent push for the increased efforts to streamline provider data management solutions is the 21st Century Cures Act.

While preparing for APIs, health plans are prioritizing the quality and accuracy of their provider data since data quality will be transparent to consumers. Whenever a plan’s provider directory changes, CMS now requires updates to that data within 30 business days. Plans that exceed this timing will also build trust with consumers, who have come to expect real-time accuracy from data.

At Ribbon, we understand that unlocking the full potential of provider data can improve so many aspects of our care. Getting it right means opening the doors to the next generation of advancements in healthcare. Learn more about how we’re thinking about the future of provider data management solutions and its’ impact on the patient journey, download our ebook, Simplifying Healthcare Navigation.

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