Quest Enterprise ServicesTM (QESTM)

MEETING THE CHALLENGE OF PROVIDER DIRECTORY ACCURACY

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The Importance Of Provider Directory Accuracy

Provider data changes dynamically and can be a challenge to maintain. Yet, your members depend on its accuracy to receive access to the care they need to lead healthy lives and avoid unnecessary, costly care. Additionally, regulators need evidence that you’re providing the right level of network adequacy based on accurate information ensuring member access.

Inaccurate Provider Data

According to The Centers for Medicare & Medicaid Services’ (CMS) third-round review of Medicare Advantage Provider Directories, nearly 50% of Medicare Advantage Plans have between 30% to 60% inaccurate data. Think of it another way…members seeking provider information receive the correct data (i.e., the correct phone number, address, panel status) only 40% to 70% of the time. This exposes health plans to multiple risks including compliance, surprise medical bills, member dissatisfaction and lower Star Ratings. Ensuring consumers have adequate access to the care they need and can find that care with accurate directories is why regulators are starting to bring more attention to health networks where providers have excessive addresses or multiple unrelated specialties.

THE INEXTRICABLE LINK OF NETWORK ADEQUACY AND PROVIDER DIRECTORY ACCURACY

While accurate provider data is important to your members, removing inaccurate provider data from your network can have a drastic effect on your network adequacy. You need a system that helps you understand how managing your provider data accuracy will impact your network adequacy.  Only Quest Enterprise ServicesTM (QESTM) can provide you with the insights you need to measure, manage and monitor your network, so your members have the access they need to care.

Verified Provider Data And The Accuracy Index Score

You need to understand the state of your provider data – the good, the bad and the ugly. Our Quest Enterprise Services (QES) Accuracy solution provides you with an Accuracy Index Score enabling you to analyze, report and act immediately on what’s right, wrong and missing from your provider data. You can quickly identify and address high-risk challenges, like invalid NPIs, OIG exclusions, excessive specialties or addresses and prioritize remediation efforts. At the core of our Accuracy Services is Quest AnalyticsTM verified provider data.  With QES, we verify your data against trusted sources like the Office of Inspector General (OIG), National Plan and Provider Enumeration System (NPPES) and other proprietary sources. Our verified data sources meet stringent requirements and are focused on providing a comprehensive view of your provider directory data. We prioritize Federal and State-mandated data attributes to ensure you are seeing the information you need to maintain compliance.
  • Completeness – Are critical attributes present in the data?
  • Eligibility – Are the NPIs valid or under sanctions?
  • Validity – Have the attributes been verified?
  • Integrity – Are the attributes realistic (i.e., excessive addresses or specialties)
  • Standardization – Are the attributes in the standard format?
  • Enrichments – Is there additional verified information available that wasn’t available in your data?

Our Provider Data Accuracy Services

You need to analyze data at the provider level. Our Provider Directory Accuracy solution allows you to view your attested and verified provider data with a variety of different lenses that check the data for:

Actionable Insights & Reporting

QES Accuracy helps you prioritize your team’s time around the providers that will most impact the adequacy of your network with two available reporting options.

First, the Actionable Provider Report(APR) helps you focus on the most critical error by location. The APR allows you to promote those providers in your directory with data you are confident is accurate, demote those that need further inspection and remediation, fix the data that can be corrected and note the changes that are made for future audits.

Second, is our secure REST Accuracy API that lets you retrieve your network provider data programmatically, with a comprehensive view of the latest information for your providers, along with the verification date and source.

Retrieving this data through an API can provide speed and efficiency to your accuracy workflows by allowing you to create business-specific rules to address different categories of errors automatically. You can then use those business rules to determine which updates you want to ingest automatically, and which updates you want to flag for further review by your team before ingesting the data.

And it helps you meet the requirements of the No Surprises Act for timely directory updates.

BetterDoctor Outreach & Attestation

For our QES clients, Quest Analytics performs outreach and attestation services as a component of the QES Accuracy offering. Data from our outreach is stored in the BetterDoctorTM Exchange, a national clearinghouse for primary sourced, continuously updated provider data.

SOLVE YOUR PROVIDER DIRECTORY ACCURACY CHALLENGES TODAY

Our team is ready to help you address the challenges provider data presents. We want to help you take your member experiences to the next level and avoid regulatory risks, like audits, and meet the mandates around surprise billing.

Contact us today to book a strategy session to understand and provide guidance to limit your exposure.

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