Maintaining complete and accurate provider data is one thing. Compliance with CMS requirements for quarterly outreach to your entire contracted network is yet another. It can be a daunting task for health plans and can pose an unwelcome burden on contracted providers.

Why the Need for Provider Outreach?

Any time CMS has measured accuracy of health plan provider data, one thing is clear: there’s a lot of room for improvement. In recent Medicare Advantage (MA) audit reports CMS calculated the percent of contracted provider locations with inaccuracies for 52 MA Organizations (MAOs) to be 44.9% with 28 out of the 52 MAOs having between 30% and 60% inaccurate locations. Inaccuracies with the highest likelihood of preventing access to care were found in 41.7% of all locations.

As a result of these challenges, CMS has instituted a number of initiatives and requirements. One that has proven to be particularly challenging for plans to effectively administer is the provider data validation process.

CMS expects MAOs to contact all of their contracted providers on a quarterly basis using a method that is likely to achieve the highest response rate to confirm and update their ability to accept new patients, their street address, phone numbers, and any other changes that affect patient access. Additionally, plans are expected to update directory information any time they become aware of changes within 30 days.

Technology to Optimize Data Validation Results

Some of the challenges plans face in administering this process include:

• Determining who performs the outreach and what method is likely to achieve the best results.
• Deciding how to sequence the outreach, ensure compliance, and optimize the results.
• Ensuring that updates are captured and disseminated to the directory and other applicable areas within the MAO
• Executing a solid plan to sustain both the process and the results (in a cost-effective way).

Curatus believes strongly that the industry is in a better position today than ever before to rely more on emerging health information technology to improve the accuracy of provider data. We also recognize that we are not yet to the point of being able to rely solely on technology and of course, plans still have compliance obligations.

Our solutions offer a complementary blend of technology advancements over legacy solutions as well as automated provider validation administration and tracking that is all built in to our ProviderLenz platform. This ensures full compliance and tracking for MAO clients and optimizes provider data validation outreach over time to ensure that plans are meeting all CMS requirements including the “most likely to achieve the highest response rate” requirement. All this, while also improving the quality of their data over the long-term utilizing all available means. Our platform is always looking at every available data source including data given by the providers themselves through the validation process to ensure the most complete and accurate set of information.

Comprehensive Compliance Functionality

In addition to provider validation compliance, ProviderLenz also features additional automated compliance functionality like continuous Network Adequacy monitoring, Provider Preclusion administration, and W9 Administration.

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/