Imagine browsing through your health plan’s provider listing on their website, using the phone number provided to call and make an appointment with an in-network provider, and finding that the phone number is not in service. Or referencing the listed addresses to find a nearby doctor, only to find out they moved from that location three years ago. Or perhaps looking for an in-network provider, and finding out after the fact that the physician is actually out-of-network, and their network status had not been updated accordingly in the provider directory.
This is the unfortunate reality for many members. With roughly 1 million physicians in the US, and an estimated 20% of provider directory data changing each year, it is difficult to keep up with changes and maintain an accurate directory. In fact, a recent CMS study revealed 49% of provider records had at least one inaccuracy. Furthering this issue is a lack of standardized unique identifiers. National Provider Identifiers (NPIs) are used inconsistently, or not at all, while facilities and groups often change names and go through mergers and acquisitions.
Provider data fuels many parts of a health plan organization–network management, call centers, claims, billing, compliance, case management, credentialing, risk adjustment, and member experience. Health plans spend 2.1 to 2.3 billion dollars annually to maintain provider directories, but the ability to maintain updated provider data has an impact that reaches far beyond just the health plan.
For members, a provider directory is often their first step on the path to seeking appropriate care. Inaccurate data causes a frustrating experience and creates a significant barrier to accessing care in the process. It can even leave members with surprise out-of-network bills for what they expected to be in-network when provider records are not accurately updated to reflect network status changes. For providers, inaccurate data is costly and an administrative strain, with physician practices spending $2.76 billion on updating provider directories annually.
Clearly, a provider directory that acts as a single source of truth is critically important to both health plan operations and the member experience, but how exactly is a “gold standard” provider directory created?
Leverage a wide array of data sources. Often, provider directories rely on one or two sources of information. Castlight leverages a number of sources, including core provider directories to gather data across 35 medical plans, 19 dental plans, and 8 behavioral health plans, but also supplemental data sourced from nearly 30 quality data sets including CMS, IQVIA, Leapfrog, regional coalitions, provider analytics firms, and more.
Refresh the data regularly, as provider data can change frequently. Health plans often rely on providers to proactively update information, which is a manual, time consuming process. Castlight uses data intelligence to regularly update records by identifying the most accurate information for each provider across various data points from multiple sources.
Avoid record duplication by grouping similar records together. Provider duplication within directories is a common occurrence, often stemming from widespread mergers and acquisitions of facilities and groups. Variations of the same provider’s information often surface within a single provider directory. For example, Dr. John Smith and Dr. J. Smith may be the same physician yet have two separate records listed in the provider directory. Castlight uses data intelligence and cross references provider attributes across core provider directories and a reference set to obtain the most reliable value. By comparing standard attributes such as address, phone number, and years of experience, Castlight is able to produce a single, accurate record for each provider.
To go one step further, match quality data to the provider record. Health plans have an opportunity to steer members to appropriate care by incorporating quality scores into provider directories. Castlight matches third party quality information to the right provider record to deliver a comprehensive member experience. This allows a member to not only find a provider that’s in-network, but to search on the basis of quality to find a high-value provider–all in a simple, user-friendly experience.
By ingesting large sets of data and leveraging our technology to group records and add quality scores, Castlight has built a Unified Provider Directory: one record per provider with a unique identifier, with standard attributes in a standard format for a positive member experience. Out of roughly 1 million physicians in the US, Castlight has 909,904 physicians in our Unified Provider Directory. Of these, we have resolved practitioner duplications across health plans by an average of 10%, corrected almost 25% of practitioner addresses and 20% of practitioner phone numbers, and corrected 45% of hospital phone numbers.
Looking forward, provider directories will only continue to grow in importance, as members looking for a consumer experience similar to other industries demand more information and transparency about their healthcare choices. Policy is also shifting to support this trend, with the release of two rules by the Centers for Medicare and Medicaid Services that aim to grant consumers access to more information, which will subsequently increase the necessity of accurate provider data to ensure transparency.
Provider directories are already critical in steering members to appropriate, in-network care–whether through accurate data that has integrated quality scores for an intuitive search process for members, or leveraging provider listings for defining narrow networks. With the right solution, it can be made significantly easier to positively impact the healthcare experience through accurate provider directories.