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Provider Directory Regulations and Systems
Overview, Challenges, Strategy, Adoption, & The Way Ahead
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Provider Data Overview
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Show of Hands! Who in this room is familiar with the term “Provider Data”? Who in this room has dealt with the challenges of “Provider Data” – specifically surrounding demographic information? Who in this room would like a better understanding of the provider directory regulations along with the systems and processes required to collect and maintain accurate provider data to minimize directory risk?
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What is “Provider Data?”
Contracts Networks Accepted Effective/Term Dates Payment Rates Demographics Addresses Phone Numbers Male/Female Age Accepting New Patients Credentialing Board Certifications Education Verification Licenses Sanctions Plan Specific Information Patient Loads Patient Ages Seen Numerous Identifiers Specialty Business Relationships Tax ID/SSN Practice Specific Details Awards and Recognitions Hospital Affiliations Ratings & Reviews Handicap Accessibility Office Hours Etc. Etc. Etc.
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Federal/State/Private Marketplaces Health Information Exchanges
How Does the Information Move? Federal/State/Private Marketplaces Health Plans Health Information Exchanges Provider Members/Patients Regulators/Accreditors
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How Do We Receive/Verify “Provider Data?”
Delegated Credentialing Dental Grid(+)
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-The Provider Data Spectrum
Why do we collect it? -The Provider Data Spectrum License Verification Phone Numbers Office Hours Sanctions Networks Language Spoken NPI Patient Loads Office Hours Addresses Mailing Billing Practicing Covering Tax ID Payment Rates Medicare ID Ratings & Reviews Hospital Affiliations Group Affiliations Payment Info
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Operational Data Tables and Consolidated Data Marts/Warehouses
Where do we store all of this information? Credentialing & Directory Validation Provider Lookups & Data Maintenance Contracting - Emptoris - Core Processing - Facets - Credentialing Operational Data Tables and Consolidated Data Marts/Warehouses
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So Who Are the Players? Large Groups, IPA’s (Groups of Groups) Groups
Individual Providers 3rd Party Sources Internal Systems Data
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“Provider Directory” Regulations
New “Provider Directory” Regulations
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What are the Directory Regulations?
CMS Medicare Advantage (MA) and Medicaid regulations Regularly evaluate availability of contracted providers and update directory Quarterly communications to providers to update availability and panel status Updates to online provider directory within 30 days of change notification Health and Human Services (HHS) regulations, applicable to Qualified Health Plans (QHPs) Renewed focus on network adequacy standards, reporting on provider accessibility for individuals with disabilities, network data collection Increase updates to provider directories for non-address data fields, including open panel status, medical group and institutional affiliations, specialties NCQA Accreditation Standards – Provider Network Management Regularly assess the accuracy of provider directories EQRO Accreditation Standards – Provider Network Management Directory needs to be updated daily during the business week
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“Plans should contact their contracted providers on a quarterly basis to update information in the provider directory.” How is BCBST solving this today? Paper “Data Verification Form (DVF) mailed via USPS Reporting showing date sent Bundled if going to same address Spread out over the quarter
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Assessing the Directory
NCQA REQUIRES: Using valid methodology, the organization perform an annual evaluation of its physician directories for: Accuracy of office locations and phone numbers Accuracy of hospital affiliations Accuracy of accepting new patients Awareness of physician office staff of physician's participation in the organization's networks. Based on results of the analysis performed in Element C, at least annually, the organization: 1-Identifies opportunities to improve the accuracy of the information in its physician directories. 2-Takes action to improve the accuracy of the information in its physician directories.
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Updating of Provider Records
Paper DVF received and manually processed 10 Full Time Contractors Reporting to ensure 30 day TAT and to help identify areas for improvement NCQA and CMS …The organization updates the physician and hospital directory within 30 calendar days of receiving new information from the physician…
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Internal Compliance Audit
Does the directory match the last received update? When was the directory last updated? Does the name of the provider match that of the NPI? Is specialty listed correctly? Is the phone number a member would use to make an appointment? Is the address listed in the provider directory correct? Is the practice name correct? Is the provider practicing as a PCP or Specialist? Is the office staff aware of what BCBST networks the provider accepts? Is the provider accepting patient status correct? Are the locations office hours listed correctly? Are the provider’s hospital affiliations listed correctly? If any information was inaccurate was the plan notified by the provider? When? Date of last DVF sent and received.
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Challenges
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ABC Primary Care Associates United Pediatric Group
What makes this so difficult? RELATIONSHIPS! Doctor Smith Doctor Jane Doctor John Doctor Elliott Doctor Doe Doctor Bronson Doctor Perry Doctor Jones ABC Primary Care Associates Urgent Care Clinic Ear, Nose & Throat of TN United Pediatric Group The Oncology Group OB/GYN Associates The Women’s Clinic Practicing Covering ABC Regional Medical Center XYZ Hospital Assoc of America Inc. Affiliation
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What feedback are we hearing?
Providers are not happy with the frequency or method of outreach. Majority of data inaccuracies are around provider location. Movement of data from source of truth to another database creates integrity issues. Provider’s staff that interface with member’s can not speak to individual network participation.
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Strategy
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Creation of a “Provider Directory Oversight Team
Quarterly Outreach Processing requested DVF changes to update the directory within 30 days. Address all directory accuracy related inquiries within 30 days Complete all directory related audits of provider data. Perform the internal compliance audit of the directory in accordance with regulatory standards. Identify root causes for directory issues and work with cross functional teams to make systemic corrections.
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Provider Contact Preferences
Provider Contact Preferences Tool Please update your contact details and contact preferences for each business function. This will allow us to reach you most effectively. We commit to not send any unnecessary communication. Last updated on 04/12/2017 Credentialing Contracting Correspondence Directory Validation Mr. John Smith Mrs. Lois Landon Mr. John Smith Ms. Janet Keo @ 2766 West Oak Street Chattanooga, TN 73737 (423) Provider Portal @ 1243 Main Street STE 34 Chattanooga, TN 73737 (423) (423) Provider Portal @ 2766 West Oak Street Chattanooga, TN 73737 (423) (423) Provider Portal @ 2766 West Oak Street Chattanooga, TN 73737 (423) (423) Provider Portal (423) (423) (423) (423)
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The Good, the Bad, and the Ugly
PROS We control the content and outreach timing We validate our records and therefore our directory CONS Provider receive this type of outreach from multiple payers Paper is not a preferred method for providers
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Phone Survey Telephonic outreach to 54 NPIs a month (648 NPI’s annually) Annual confidence level of 99 % with a 5% margin of error Meets NCQA requirement Allows us to evaluate ourselves using the same scoring as CMS, NCQA and BCBSA and develop solutions for improvement See the directory issues from a member’s viewpoint
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Adoption
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Pros vs. Cons If response is questionable manual review and outreach to the provider to confirm Illegible handwriting Faxes can get cut off in transmission Every document must be touched manually
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The Way Ahead
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Coming 4Q2017- DirectAssure 2.0!
Future Improvements All practitioner outreach will happen electronically through CAQH’s DirectAssure product. Remove some of the manual touch points and begin some automation of data entry. Create motivators for the providers to respond to outreach and train front office staff on network participation. Coming 4Q DirectAssure 2.0!
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Rome wasn’t built in a day!
Putting it all Together in One Slide PARTNER Simply stated: Our providers are in business to take care of their patients. Words like: Data, Directories, Insurance and Claims are just noise providers have to deal with in the scope of their core mission. Maintaining their data with payors will ALWAYS be second to ensuring their patients are as healthy as possible. EDUCATE Our providers are half of the reason we are in business today. As long as we have members who utilize the healthcare system we will need providers to deliver that care. Our providers are our partners and we need to work together to solve our provider data challenges. Providers must by knowledgeable of the rules and regulations governing provider data oversight. Without knowing why we need this information it will be very difficult to collect and maintain it. Appreciate COMMUNICATE Patience Rome wasn’t built in a day! Changing behavior takes time and commitment. Data needs to be captured to analyze data quality improvement measures. CONSISTENCY Be transparent with our provider partners when performing outreach. Pay attention to feedback! The success of this provider data initiative will hinge on consistency. Consistency in education, communication, our partnerships, patience on both sides and appreciation of conflicting needs.
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