Provider Directors – to the consumer – probably seem like an easy task to maintain and, essentially, a no-brainer. After all, all a health plan has to do is collect certain pieces of information from providers in its network and ensure that it is update frequently. It would, moreover, seem to be a task that one would want to maintain as a feature of basic customer service. That said, the problem is a lot more complex than one would think. There does not yet exist one single source of truth for provider information; thus, each health plan keeps its own records and has to audit and update them manually. Manual audits of provider data cannot be done continuously and, therefore, the provider data that patients depend on to ensure that a provider is in-network and to compare health plans is often woefully inaccurate leading to beneficiaries being unable to make educated decisions about specific plans.

            In response to a request made by a Medicare Advantage beneficiary, CMS reviewed provider data and found that nearly half of the time, there were errors in the data. Additionally, CMS reported, that the inaccuracies were not isolated to a few organizations (whose large numbers may have skewed the results); rather, the inaccuracies were rather widespread. This would seem to indicate that there is either industry ambivalence towards ensuring directory accuracy or there are technical or process limitations that is rendering accuracy difficult. To incentivize health plans to keep their provider directories up-to-date, the government has increased the fines significantly; however, CMS did not offer a framework to provide a single source of truth for health plans to build upon.

            Industry collaboratives have sought to facilitate more coordinated updating of provider directories to promote accuracy and timely updates; indeed, some experts have posited that this could be a good use of blockchain technology due to the distributed nature of the various health plans’ data repositories. There would, of course, need to be rules about which updates to accept and what mechanisms would be put in place to ensure that an organization requesting access to a provider’s information, indeed, has the right to it. For example, there may need be a parallel blockchain or other rules-based system that can adjudicate whether or not a requesting health plan has the provider in-network before allowing the data request to continue.

            Synaptic Health Alliance is one such industry collaborative that is seeking to build a private blockchain. This collaborative includes parties such as Optum, Ascension, Aetna, Humana, and Quest Diagnostics. Unlike blockchains such as Bitcoin or Ethereum, the blockchain envisioned by Synaptic Health Alliance would be private (closer to Ripple) and permissioned. Eventually, if their pilot project succeeds, it could encourage other participants to get involved and to share non-proprietary data with the network – thereby leading to a situation where the collective administrative burden is reduced.

            Provider directory inaccuracy is not only a regulatory burden and a cause of frustration for consumers – it is costly. Hospitals, health plans, and physicians spend over two billion dollars a year to update provider directories. Additionally, the average provider is affiliated with over twenty providers and is required to update the provider directory for each one separately – there aren’t even centralized state provider directories that could be used to reduce the administrative burden. High error rates can lead Medicare Advantage plans from being barred from marketing or new enrollment and for fines of up to twenty-five thousand dollars per day per beneficiary. It looks like the amount of pain being inflicted on the healthcare community is sufficient along with the availability of viable solutions to begin to create momentum towards developing industry wide solutions to resolve this pain point.

Categories: Healthcare

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