Dealing with the Pain of Provider Directories

I’ve been in the healthcare industry for many years now and I can’t tell you when I have ever had so many conversations about provider directories  as in the past few months. My health insurance colleagues and I continue to be amazed at how challenging it has become for payers to provide accurate and up-to-date directories for their members.

The pain seems to be escalating.

You would think with all the technology advances, it would have gotten easier, especially now that  the requirement to produce hard-copy versions is only upon request. Instead it has gotten harder to deal with the pace of change surrounding multiple plans and provider affiliations, and the deluge of data.

The penalties are certainly escalating.

It is evident that payers are facing significant fines – for example, up to $25,000 per Medicare Beneficiary per day – as well as higher than expected out of network cost because members lack accurate information about whether a provider is in-network or not. 

Of course, it’s not just a payer issue as they are ultimately dependent on the providers to share accurate and timely data. However, it is a payer responsibility.  And even if they are getting accurate data, payers still struggle to manage the provider data to insure that everyone in the organization has consistent and appropriate views of the data in a timely manner.

I saw the following example recently in the CAQH whitepaper, Defining the Provider Data Dilemma, that addresses the industry-wide provider data challenge:

“To illustrate the point, a typical practice holds, on average, 12 managed care contracts with health plans at any given time, and each health plan requires approximately 140 different provider data elements for contract management. A practice with five providers and the average number of managed care contracts must manage 8,400 data points.”

Progress is being made.

AHIP, CAQH and others are taking steps to simplify the credentialing and updating process. A  single portal for provider data updates shared with all payers would be an important advance. However, even with this advance, most payers still use ineffective processes with spreadsheets and databases to manage the provider data across their current and legacy systems.

A digital transformation platform approach though could leverage industry progress and eliminate much of the current manual efforts. For example, the Appian low-code digital platform and case management capabilities can create a single source of truth for sharing with all of your legacy systems. And, payers can automate those manual processes using the process modeler, which provides the ability to drag and drop objects to mirror your desired process and then generate solutions without having to use complicated coding.

That’s just a high level look at how Appian can help. To see more on how Appian can provide accurate provider data and directories, along with cost savings, check out this industry brief that lays out exactly what Appian can provide.

Want to discuss how Appian can assist your company’s specific provider directory needs? Send me over an e-mail to polansky@appian.com and we can set up a time to chat.