Ensuring that Medicare Advantage members have accurate information about the providers in a plan’s network has never been more important to MA organizations, as CMS has made a push in recent years to improve directory accuracy and is now regularly auditing online directories. But giving members the wrong information can also affect star ratings and has the potential to negatively impact health outcomes. That’s why plans are employing a multifaceted approach to improving directory accuracy and are seeing what sticks.

“It’s definitely top of mind for all clients, and it’s a significant undertaking,” Lucia Giudice, Deloitte Consulting’s managing director and government programs practice leader, tells AIS Health. “And it’s not like plans have a push-button system to [conduct outreach], so they are trying everything: periodic calls, newsletters, email blasts, getting rosters from the bigger groups and doing automatic uploads for those, and self-service portals.”

“It’s a systemic issue across all the plans we’ve seen and it’s the same issues across the board, partly because the information is just bad. And if it’s good today, it’s bad tomorrow,” weighs in Bobby Vaitla, senior manager for health plans at Deloitte. “One of my clients gets 1 million-plus requests per year for changes of data, like service locations, specialties, terminations. How do you keep a million changes live and at the same time let the downstream stakeholders use that data to pay the claims, assign primary care physicians, etc.? It’s a big challenge.”

CMS intensified its oversight of provider directory accuracy with a pilot launched last year by the Medicare Drug & Health Plan Contract Administration Group. The first round of reviews showed that, for example, 45.1% of provider locations listed in the online directories reviewed were inaccurate (MAN 1/26/17, p. 1). CMS’s goal is to review one-third of contracts each year, and the agency has begun issuing civil monetary penalties, notices of noncompliance and warning letters for deficiencies — all of which can impact a plan’s Past Performance Analysis results that CMS can use to deny applications.

“There’s the regulatory impetus for the [plan] focus on it, but it’s a business problem and even if CMS wasn’t auditing provider directories,…plans need accurate, complete provider data to run their business, especially with value-based care arrangements and things like that,” adds Giudice. “So they should be looking at it anyway, but like most things, sometimes a regulatory spotlight gets people to focus on it.”

The provider directory is “the way most of your members really touch and enter your system for the first time. If they go in and they try to find a doctor or try to find a telephone number or address and any of that information is incorrect, it makes them rather unhappy and it also leaves them with a feeling that, ‘My plan really doesn’t know what they’re doing,'” remarked Gale Arden, vice president for complex care with Centene Corp., during a Sept. 26 session at the America’s Health Insurance Plans (AHIP) National Conference on Medicare in Washington, D.C. And if that results in a member registering a complaint with CMS, it can lead to a deduction in star ratings, she pointed out. “And of course, you want your member to be able to get to their provider, to be able to make appointments, because if they can’t connect with their provider, it comes out in terms of their health and their health outcomes,” added Arden.

Moreover, it’s important to ensure with marketing and enrollment efforts that plans are providing potential enrollees a complete picture of what they offer, including in their online provider directory. As part of its focus on transparency, CMS does not want plans “to misrepresent their networks in any way, so as open enrollment [approaches on Oct. 15], if you know that a provider is leaving the network sometime in that first six months or so, [CMS wants] you to disclose that so that a potential member doesn’t end up joining your plan only to find out that the doctor they thought was in your network has just terminated,” explained Arden. “So with that in mind, they want you to be able to communicate significant changes.”

Varying Products, Networks Complicate Efforts

With multiple lines of business and provider locations, provider directory information is just a “slice of a much, much larger data set” that is used to pay claims and conduct other business, and “all of that data is constantly shifting,” added Kenneth Wrzos, senior director for operational excellence at EmblemHealth, a New York-based insurer that serves more than 160,000 MA enrollees. Hindering the task of collecting accurate information is that provider office staff can often be confused about participation, especially as the landscape has become more complicated, he told attendees. For example, a provider may participate in only one particular network or product, and within practices, not all providers may be in-network, so “you have to go through a whole checklist and that makes keeping the directories straight difficult.”

And while plans would love to rely on providers to proactively update their information, the feedback from providers has been that they have very busy offices and it’s just not a priority to update all the insurance companies they deal with when there is a change, Wrzos continued. That was illustrated in a study conducted last year by AHIP in which it took an average of 7.1 notifications from one vendor to complete the provider directory validation process, with only 18.6% of providers finalizing those steps (MAN 3/16/17, p. 3).

EmblemHealth controls only 23% of provider locations, meaning that 77% of the time the insurer is dealing with data from a delegated entity, explained Wrzos. After an internal audit showed that only three out of its 10 highest-volume submitters were providing up-to-date information, EmblemHealth created a “front-end validation team” to assess inbound data files. Rather than “loading blindly,” it conducted phone calls to a sample of providers to test the accuracy of the data and send back files that were only partially accurate. A provider network management department then works with the sample group to straighten out the data, he said.

Other tactics deployed to improve EmblemHealth’s directory accuracy include:

  • Conducting internal provider directory auditing, which he said gives insights into quality, leading the insurer to increase them from a quarterly to a monthly basis.

  • Using analytics to do a “data cleanup.” Wrzos said, “If you haven’t received a claim from a location in 12 months or more, chances are it’s not a good location, so we look at those and go through a process to validate and suppress them from our directory.”

  • Performing “automatic roster reconciliation” with larger groups, whereby the providers submit whatever information they can in a format of their choosing, as long as they include certain data elements. The insurer will “crosswalk” that information with its own system and automate certain additions, changes and deletions. EmblemHealth piloted this process with a group called AdvantageCare, which improved its directory accuracy from 65% to 95%, and has since begun similar work with three other groups.

To tackle the issue of provider directory accuracy, Arden recommended both provider education/outreach and internal monitoring. She said Centene is currently making about 3,000 calls every month to providers to validate information or gather changes. Portals that allow providers to sign in and make changes are another option, although how effective they are is debatable, she said. Additionally, she recommended that sponsors include dashboards to “assess trending” and find “the points in your tracking system that are not working.”

“It’s a lot of work. There is no one thing you can do to make your directories totally accurate, unless you have one major database that is totally up-to-date every day,” remarked Arden. “But I’d advise plans that when you do your work on provider directories, you do this work from the viewpoint of the member.”

“We don’t want our members to be unhappy; we want them to have good experiences. Every bad experience is potentially a lost member,” added Wrzos. “And insurers want to have good relationships with their network providers.”