Improving Provider Directory Accuracy in an Evolving Regulatory Landscape

August 2017

There has long been an industry imperative to improve the quality of information in health plan provider directories. Over the last two years, new federal and state regulations have added pressure, requiring strategies that prioritize error removal and strengthen provider engagement.

Federal regulations now require Medicare Advantage, Medicaid and Qualified Health Plans to conduct routine provider outreach or submit more frequent updates that can include monthly reporting. Plans can be subject to financial penalties if found uncompliant.

Many states have also begun creating their own directory requirements. In 2015, the National Association of Insurance Commissioners issued model legislation for states, which contains requirements for provider directories. Currently, 28 states, including the District of Columbia, have enacted requirements on provider directories with about half specifying frequency of the updates.

Working with health plans to address these challenges, CAQH has found ways to improve data accuracy in directories to reduce the risk of penalties and provide better information for patients seeking care.

Findings by the Centers for Medicare and Medicaid Services (CMS) demonstrate strategic opportunities for health plans to focus on solving the most prevalent directory deficiencies. According to a recent CMS review of provider directories, an overwhelming 66 percent of location inaccuracies fell into the category “provider is not practicing at location.”

Questions that clarify location issues have been integrated into DirectAssure®, the CAQH solution integrated within the CAQH Proview platform that enables providers to easily review, update and confirm their practice information for directories. CAQH audits have found—and UnitedHealthcare and other health plans have confirmed— that this enabled plans to suppress invalid locations between 77-80 percent of the time.

CAQH continues to make enhancements to the solution. In April, phone number confirmation was added to the questions providers must answer, and preliminary results show that the rate of phone number changes has increased 300 percent. Later this year, providers will be asked to confirm their insurer participation, based on data supplied by each health plan, and if they are accepting new patients for each location within the provider profile.

As the regulatory environment evolves, DirectAssure supports health plans in their work to improve accuracy and meet regulatory timeframes while lessening the administrative burden on providers through more strategic outreach.

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