A Three-Pronged Approach to Improve Provider Network Adequacy: Part 1

by | Mar 25, 2021 | Healthcare

Learn more about the many provider network adequacy issues facing health plans.

It’s no secret that phoning and faxing providers to collect and update data doesn’t work. And yet, here we are in 2021 and modern healthcare organizations are still entrenched in a massively outdated process that is expensive, cumbersome and most importantly, ineffective.

Top four reasons

  1. Untrustworthy sources
  2. Overly burdensome
  3. Inordinately expensive
  4. Unreliable results

Untrustworthy Sources

The phone rings at an urgent care center. Someone answers. Is it an intern on their first day? A seasoned office manager? Who knows? Nevertheless, they are asked if Dr. Patel works there. Dr. Patel is a consulting specialist and only visits the clinic on Fridays. However, the person on the call doesn’t work Fridays and doesn’t know Dr. Patel. They answer that no, Dr. Patel does not work there. End of call.

Similarly, the provider services team at a health plan receives a fax with handwritten updates from a small practice. The services team has no idea who filled out the fax or their qualifications. Further, the handwriting is difficult to read and must be manually interpreted and entered into the system.

These encounters happen all day, every day. It is astonishing that health plans rely on information gathered from random people answering the phone or replying to a fax for anything, never mind for important business processes such as maintaining their contracted networks.

To be clear, health plans are never going to talk or fax directly with the busy physician. At best, plans connect with junior administrative staff who rarely have a complete picture of a provider’s contract-level commitments to a given health plan. To further complicate the outreach, many physicians contract indirectly with health plans via provider organizations such as IPAs and MSOs, which makes it even more unlikely that front desk staff at the practice are privy to the details of these agreements.

Resulting problems:
  • Unreliable information gathered from unqualified sources
  • Manual system of data collection is resource intensive for plan and provider

Overly Burdensome

Administrative overhead for providers

The average physician contracts with eight health plans across multiple plan products. Because different products require different data, each plan requests around 140 different pieces of information. This means each physician must manage more than 1,000 pieces of data across multiple formats and reporting frequencies throughout the year. For a practice with three physicians, that’s well over 3,000 pieces of information to provide via telephone and fax machine over and over.

Administrative overhead for health plans

From the health plan perspective, this three-physician practice is one of thousands of service sites. The complexities compound exponentially. It is not uncommon for large national plans to have teams of people re-keying information collected via faxes and phone calls.

Let’s talk rekeying

Every time a person re-enters information, an opportunity for error arises. Even the most diligent person makes mistakes. The more manual the process, the more error-prone it becomes.

Let’s talk resources

Ask yourself – what could all these people do if they weren’t manually entering untrustworthy data? At the provider’s office, they could support the delivery of patient-centered care. They could track progress toward value-based targets. They could process prescriptions and appointments more efficiently to boost patient satisfaction.

At the health plan, they, too, could support value-based care. They could ensure the proper coding of virtual encounters to meet new HEDISÒ requirements. They could support outreach to enroll members in chronic care management. They could do pretty much anything, and it would bring more value to the health plan than the introduction of more errors to already unreliable provider information.

Resulting problems:
  • Sheer quantity of data managed manually increases the margin of error
  • Resource-intensive processes take away from higher-value activities

Inordinately Expensive

Despite an annual investment of $2.1 to $2.3 billion by commercial health plans to maintain provider databases, outcomes are shockingly poor. There is no doubt, it is going to get much, much worse.

Regulatory history

Since 2016, the Centers for Medicare and Medicaid Services (CMS) has conducted regular reviews of provider directories for its Medicare Advantage (MA) population. Year-over-year, they discover widespread discrepancies and inaccuracies, with no discernable improvement. As in 2018, the 2020 report revealed.

  • 50 percent of providers and nearly 49 percent of locations had at least one discrepancy
  • Errors still center around the most basic information including whether providers work at a listed location and if they are accepting new patients.
  • Average accuracy by location declined from 48.39 percent in 2018 to 44.79 percent in 2020.

Penalties are significant. As it pertains to MA beneficiaries, CMS can levy fines of up to $25,000 per error per provider.

Regulatory future

The recently passed No Surprises Act brings nearly all private group and individual plans into alignment with CMS. By January 2022, for commercial populations, health plans must:

  • Offer an online provider directory on its website.
  • Establish a continuous provider information verification process.
  • Update provider information within two days of receiving new information.
  • Respond to member inquiries about provider or location availability/network status within one day of inquiry. This information is binding.

Here again, penalties are steep. They include financial responsibility by the health plan for provider costs incurred by members who receive services from providers/sites listed in the online directory or informed via inquiry, who are no longer part of the plan’s network.

Resulting problems

  • Penalties for CMS populations are high and climbing
  • Penalties for commercial populations are following suit
  • Pressure is mounting to fix the problem of inaccurate provider directories

Unreliable results

Calling and faxing providers simply does not work. It never has worked. It will never work. Phone calls and fax machines belong in anecdotes, not as an integral part of your business.

Up next in part two: Reliable, affordable provider data can be easily accessed within workflows and relationships you — and your providers — already have and trust.




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