The Health Insurance Portability and Accountability Act (HIPAA) mandated the adoption of a standard unique identifier for health care providers in 1996. The final rule instituting the NPI as the standard unique identifier went into effect under the National Plan & Provider Enumeration System (NPPES) in 2005. The system's now 15-year history begs the question, does the industry have a better handle on healthcare provider data today? The short answer is 'YES, marginally'. But there is still a long way to go.

Why the ‘Long Way to Go’?

In January 2020, CMS announced that NPPES began allowing providers to certify their NPI data and encouraged payers to “work with their contracted providers and urge them to review and update their NPPES data”¹. This is a step in the right direction if NPPES (or any would be national standard) is ever going to be the 'record or truth' AND be complete and accurate at the same time.

Referring to the agency's online provider directory reviews conducted every three years, CMS stated that, “The data collected demonstrates there has been a lack of improvement in the accuracy of provider directories over the past three years. CMS will continue its focus on provider directory accuracy at both the aggregate and individual plan-level.”²

Now for the long way to go reference. Today, only 8.2% of the 6.2 million NPIs in the NPPES database have been updated within the past year. Even more concerning, 57% of NPIs have not been updated in over 5 years, with more than half that number not being updated in over 10 years³.

While opinions vary on the 'shelf-life' of provider data accuracy, the CMS requirement that Medicare Advantage plans conduct quarterly outreach⁴ to every contracted provider to validate directory data suggests that it is fairly short. A former COO of a national health plan estimated that 6 to 8 percent of their network provider information was changing monthly. That said, the long dormancy of the vast majority of NPI records in the NPPES leaves a lot of room for improvement.

Contributing Factors

There are of course, many contributing factors to the still inadequate state of provider data accuracy, including the following key ones:

• Complexity of Information. Most healthcare providers are contracted under several lines of business with 8 or more payers. Doctors are affiliated with multiple provider organizations, each with several locations. Answers to simple questions about address, phone numbers, hours of operation, specialties, language, key contacts, and more become complicated with the matrix of affiliations.
• Unsustainable Burden on Providers. Payers are required to contact their entire contracted provider network up to 4 times each year to validate the information listed in their provider directory. Given the complexity of affiliations and other factors, the workload this creates for providers is simply unsustainable.
• Competing Uses of Provider Information. The most common and often criticized use of provider data is populating a payer's provider directory, whether electronic or printed. Basic data elements about a provider such as address and phone number might be accurate for the directory but are wrong for claims payment purposes. Payers have many uses for provider data beyond the directory and accurate information is critical to support each of those uses uniquely.

A Different Approach

Improved provider data accuracy is particularly important, but a crucial caveat is that the right solution must also maximize the amount of healthcare resources actually spent on care, as our healthcare system still expends too much of the healthcare dollar on administrative expenses. Arguably, reduced healthcare admin costs cannot always come simply through consolidation.

There are many things that can be done to improve the accuracy of provider data for all its varied purposes. Advanced data collection technology can glean information about healthcare providers from numerous active and static data sources. This approach will reverse the tide of overburdening the providers themselves, as is the case with many provider data management platforms today.

The CMS' Interoperability and Patient Access final rule requiring payers to make their provider directory data publicly available via application programming interface (API) beginning in 2021, will accelerate innovation toward more accurate provider data for all healthcare administrative purposes. Such innovations will soon become more visible.

In addition to emphasizing the NPPES repository as the right framework to become the 'record of truth' of the future, CMS should seek out emerging technologies that can efficiently curate and enrich the data contained in every NPI record held there. A structured model to automatically assess currency, completeness, and accuracy of every provider record should also be established and standardized.

How Will We Know Provider Data is Better?

While the aging of NPI record curation statistics shared here are only a single metric of how fresh the data contained in the NPPES, it is a decent starting point. Future measurements should not be overly complicated. Think Credit Score, where everyone knows an 800 means you drive the new car and a 300 means otherwise. Simple. Provider data quality (recency, accuracy, completeness, etc.) should not be much more complicated than that.

About Curatus
Curatus (formerly Animas Data Solutions) is a privately held health information technology company offering full-service provider data curation, enrichment, management, and governance to the Medicare Advantage, Medicaid, and commercial payer markets.

The company's Provider Data Management platform, ProviderLenz^SM reduces costs, provider and administrative burden, and errors. Facing off against complex and continuously changing provider data, the technology curates and disseminates enriched provider data in real-time and behind-the-scenes for ALL payer use cases based on a single 'source of truth' Master Provider Index. This means that all operational processes within a payer's organization are always using the same and most up-to-date provider data available. This is achieved with no changes to a payer's current IT infrastructure.

Learn more: https://curatus.com/providerlenz/

¹ National Plan and Provider Enumeration System as a Resource to Improve Provider Directory Accuracy (Jan 2020).
² Announcement of Calendar Year (CY) 2020 Medicare Advantage Capitation Rates, Medicare Advantage and Part D Payment Policies, and Final Call Letter.
³ NPI Aging analysis completed by Animas Data Solutions, LLC (Oct 2020).
⁴ See §110.2.2 – Provider Directory Updates, of Medicare Managed Care Manual, Chapter 4 – Benefits and Beneficiary Protections (Rev. 121, Issued: 04-22-16).