by Michael Simon

Money is at risk when it comes to Provider Directories. There has been a plethora of countless fines and millions of dollars related to judgements and customer rebates. The proactive payer will want to address inaccurate or inadequate provider directories, according to a new report from consulting firm IDC Health Insights and several other analysts.

It all starts when a member is looking for a new doctor. They use a referral or more common they check their payers’ website. There they will find a directory in the form of a downloadable portable document (PDF) or an interactive lookup tool. In some cases, they will find nothing and have to request a paper version to be mailed. The patient’s goal is simple. Where am I going for care, are they in network, what language do they speak and location.

The real problem with Provider Directories is that they are constantly changing. It is difficult for payers to keep directories updated in the event of changes in provider information, i.e. addition of providers to a practice or change of address. The information may also exist in a separate database representing linking of several legacy systems. It has also been suggested that there hidden agendas of the breadth and depth of a network as well as where out-of-network providers could leave member with large out of pocket expenses. While often times these events are unintentional by the payer, the lack of maintaining good information often leads to perceptions in the marketplace which cost reputation and money. At the highlest level, office staff at a provider often communicate and form opinions about a payer starting with the provider directory with in and out of network inadequacies.

Equally important and linked to provider directories is a solid strategy around network development, retraction and expansion. Having a solid network development strategy whether partner led or organic for on-boarding new providers and products is more often overlooked. Often times there may not be a process with network development activities for the provider directory to be updated and maintained.

A new look at provider directories and network development is needed as these areas tend to overlap. Either providers have been publishing paper directories for years which sometimes are inaccurate and or the new recruiting strategy has no defined process which leads to a disconnected directory. This could be a result of lack of process around network expansion and strategy.

Another common problem is providers simply not updating their information on a regular basis. Having a well defined process for providers to update their information is often problematic. Conceptually this should not be hard, many providers and payers do not do this very well. Some groups have been trying out new self-service portals for this type of updates.

To improve the accuracy of provider directories, I recommend payers:

  • Segment provider data separate from operational data
  • Use a non-competitive mindset – Is this worth the aggregation and perception generated in the marketplace of listing inaccurate data?
  • Use one system of record for all provider data
  • Set strategies for updates and triggers of the provider directory; can your provider updated their information in the provider directory?
  • Use a Payer CRM Like Provider Partnership to organize and structure data
  • Look for a Network Development Partner who shares the same philosophy, tools and expertise and who can build and or expand your network as well as manage and update your directory seamlessly without any work by your organization
  • Stay away from excel spreadsheets, complicated databases creating new silos of information and a staff of technical staffing – this may require just a straight forward a different mindset than found with some of the legacy providers.

Not only will the payer look organized, but the perception in the provider community would start to move in a positive direction.

Michael Simon

Provider Partnership