A Three-Pronged Approach to Improve Provider Network Adequacy: Part 3

Part Three: A Single Source of Truth that Works for Everyone

In part one of this series, we highlight how phone calls and fax requests fail to collect reliable provider data.

Part two dove into the smarter alternative – tapping into trusted relationships and workflows to obtain data from primary sources such as independent physician associations (IPAs).

To recap: Many providers and care delivery sites rely on third-party administrative entities for critical business functions to keep their medical practices operating (billing, credentialing, contracting, etc.). Both administrative entities and providers are highly motivated to ensure all information held by the entity is accurate at all times. Each administrative entity has accurate data for hundreds of providers, which in addition to improved accuracy, means less effort over time.

Innovative health plans use these primary data sources to gain key competitive advantages:

• Improved member satisfaction (better directories and access to care)

• Lowered regulatory risk
• Lowered administrative burden for providers and internal teams
• Improved network adequacy measurement and monitoring
• Improved revenue

The question is – how exactly does this work? Master Data Management (MDM) companies have promised a single source of data truth for years. Unfortunately, and after much expense and frustration, most miss the mark.

Making it work for everyone

Data management strategies must understand that each data system within a healthcare ecosystem has unique standards around managing data and priorities around which data matters. Not all systems can, want, or will make a data change, even when some data is inaccurate.

It must also be acknowledged that even if the industry agrees on a single universal data model, it will take decades before all the systems and processes that run our current system are upgraded and integrated with such an ambitious standard.

Instead, it is up to healthcare data experts to implement a data model based on the real world. One that delivers an integrated, intelligent translation within and between members of a healthcare ecosystem. A method to preserve everyone’s unique internal standards and translate them through a common data model to whatever the other party expects.

For example, if one system only sends payment via electronic transfer and does not send checks through post office mail, they do not need P.O. boxes of billing addresses. Traditional MDM solutions flag the incorrect P.O. boxes and require the system to fix the inaccurate data. However, the owners of said system do not care and are not going to spend the time and trouble of fixing data that don’t matter to them. Nor should they.

A data model built for the real world accepts that files from this particular system could always contain incorrect mailing addresses. A real-world data model takes in the inaccurate data but ensures it isn’t treated as a correction. In this way, the inaccurate P.O. box data doesn’t contaminate the whole and people aren’t asked to waste their time aligning data they do not use.

Connecting everyone

One of the biggest hurdles in connecting any healthcare system is the complex nature of the system itself. Connecting with administrative systems is fantastic for health systems and providers who have or use them, but what about those who don’t? To deliver accurate directories and guarantee appropriate access to care, health plans must connect with everyone in their ecosystem, regardless of data capabilities.

Connecting everyone requires flexibility and extensive industry knowledge. On one end of the spectrum, hospitals and large sites of care often have multiple advanced administrative systems that can connect via near real-time APIs. In the middle, are locations with electronic data, but it might be in Excel spreadsheets or an Access database. In these cases, the data is there, but it takes a bit more work to extract. On the other end of the spectrum, are practices with no data systems at all. For these providers, MDM must bring an intuitive system to them.

The ideal MDM solution can leverage, to the greatest extent possible, whatever systems and technology each provider location has, regardless of where they are on the spectrum of data sophistication.

The Holy Grail of MDM: A proven, intuitive, single source of data truth

While the search for a proven, intuitive, affordable single source of data truth may feel like the search for the holy grail, it is not. What it takes, however, is deep healthcare experience, data expertise and innovation.

We are the data management team behind one of the largest, most reliable, healthcare data exchanges in the country – the state of California’s provider utility, the Symphony Provider Directory. Symphony is a centralized directory connecting providers, health plans and regulators to share, reconcile and validate provider data.

To date, Symphony, built on Coperor E-MDM, connects:

• 14 health plans, including Anthem Blue Cross, Health Net and Blue Shield of CA

• 15,000 provider organizations
• 170,000+ individual providers

Coperor Ecosystem MDM by Gaine connects everyone. We make it work for everyone. Find out how we can make it work for you.