Solving Provider Suppression for Health Plan Success

One of the questions I frequently receive from health plans is: How can we explore alternative approaches to assessing provider directory accuracy beyond merely determining network precision?

A recurring topic in these discussions is the suppression of provider files. Health plans routinely undertake the practice of suppressing a certain number of providers from their existing network.

This action often leads to friction with their members and disrupts the overall member experience. Through strategic collaborations with national and other health plans, we have been working on a solution. We aim to examine the possibility of utilizing suppressed files, independent of current accuracy information provided by services like attestation, and integrating additional insights into lower-tier provider claims.

This process allows us to address several key questions: First, whether a provider has undergone attestation. Second, if attested, whether any claims activity is associated with them. Third, if neither of the previous conditions are met based on our machine learning algorithm, whether the provider still operates within the same territory and specialty.

By implementing this approach, we can provide health plans with valuable insights into which providers to consider suppressing from their current directory. Consequently, this will lead to reduced friction and an enhanced member experience.