Under pressure from federal and state regulators to improve the timeliness and accuracy of provider directories, health insurers are looking to software vendors for answers.
Working with the payer trade group America’s Health Insurance Plans, 12 insurers will conduct six-month pilot programs in California, Florida and Indiana, starting in April. The insurers will work with healthcare transaction processing vendors Availity and BetterDoctor to validate and update data on physicians, then update the insurers’ provider directories.
These directories have been notoriously inaccurate for years, making it difficult for patients seeking a new or different doctor to get correct information. Patients often select a physician practice that is listed as accepting new patients, but is not. Or, patients will select a physician listed as being in the patient’s network, but the practice is actually out of network.
That’s why regulators are seeking improvements in the process. The Centers for Medicare and Medicaid Services, for instance, wants insurers to update their provider directories every 90 days.
Another goal of the pilot is to ease the burden on providers when reporting changes in the practice that could affect directory information, such as different hours of service or a physician retiring.
“Rather than receiving requests or inquiries from multiple health plans, the pilot is designed to facilitate one primary point of contact for providers when updating or reporting changes to their practice information,” an AHIP statement said. “Providers may be contacted by phone, email or fax with instructions on how to update their information. BetterDoctor and Availity will then share data changes with the participating health plans to update their online and hard-copy directories.”
Participating insurers include Anthem, AvMed, Blue Shield of California, Cigna, Florida Blue, HealthNet, Humana, L.A. Care Health Plan, Molina Healthcare of California, SCAN Health Plan, WellCare and Western Health Advantage.
Russ Thomas, CEO at Availity, says the tests also are an opportunity for insurers to bring new services to providers, while engaging them to improve the accuracy of their information.
For instance, Availity may flag a claim from a provider that it’s aware of but which submitted a claim that has an address that hasn’t been attached to the provider in the past. Using the vendor’s portal platform that connects it with customers, Availity can engage a provider in real time and send an alert asking for validation of a new address. That process can boost the accuracy of provider directories while avoiding a claim being rejected because of non-validated information.
“We believe that as providers come to us all day to check eligibility, if we alert them in the workflow to data that will stop a claim, they will take the time to make the correction,” Thomas says.
Register or login for access to this item and much more
All Health Data Management content is archived after seven days.
Community members receive:
- All recent and archived articles
- Conference offers and updates
- A full menu of enewsletter options
- Web seminars, white papers, ebooks
Already have an account? Log In
Don't have an account? Register for Free Unlimited Access