Let’s address the elephant in the room – the separation of network adequacy and provider data accuracy. We all know they’re both crucial for a successful provider network. Yet they’re often treated as separate entities, missing out on the incredible synergy they can achieve. In this article, we’ll explain why they’re interdependent and give you some strategies for bringing accuracy and adequacy together.
The Dilemma: Accuracy vs. Assumption
Imagine you are conducting a network analysis to evaluate the adequacy and effectiveness of your provider network. Your analysis suggests that you have enough providers to meet demand, but members still report issues scheduling appointments. What gives?
The answer lies in provider data integrity. While you may have all the network providers in your database, you can’t easily identify the last time they verified their information. Without a paper trail, it’s difficult to know if a provider has relocated or retired since the last data update. This oversight can have far-reaching consequences that impact your entire company.
A Deeper Dive: Let's Go to Brown County, Wisconsin
To illustrate the impact of outdated provider data on network adequacy, let’s say you need to understand your Primary Care coverage in Brown County, Wisconsin.
When you look at your health plan’s provider database, you see that you have 9 Servicing Providers for Primary Care. At first glance, things seem promising—you have enough providers to meet the requirements, ensuring timely and accessible primary care for your beneficiaries. Yay, right?
Not so fast! When you dig deeper, you discover the harsh truth. Out of those 9 providers, only 1 has verified the required information in 90 days. As a result, you must suppress the other 8 providers to comply with provider directory accuracy regulations. It’s like uninviting party guests because they failed to RSVP in time. Not quite the celebratory network adequacy you wanted.
The Provider Specialty Gap: When Having One Provider Isn't Enough
After suppressing those eight providers, you’re left with only one Primary Care Provider to service the county. Unfortunately, this solo provider isn’t enough to comply with network adequacy requirements. Now, you have a specialty gap that needs to be filled ASAP.
Strategies for Success: Achieving Accuracy and Adequacy Together
We don’t want to leave you hanging without a few practical solutions. To tackle the challenges posed by network adequacy and provider data accuracy, it’s crucial to have a comprehensive solution and approach in place that can handle these complex issues. Here are three tips to help you bring provider data accuracy and network adequacy together.
Implement a process for regular provider data cleanup. This involves verifying and updating information, identifying changes, and suppressing providers who do not fulfill verification requirements. Think of it as decluttering your digital Rolodex – keep only the providers who are actively playing the game.
Establish a defendable provider verification process. This process should include a strong provider outreach strategy to ensure your providers are regularly updating their information, and that you have a way to conveniently receive updates. After all, you don’t want providers who ghost you.
Tip: Gain a better understanding of what’s working well and what needs improvement in your current process by using our Provider Data Accuracy Essential Planner.
Get Your Free Provider Data Accuracy Essential Planner
Elevate Your Provider Data Accuracy with QES Accuracy
Network adequacy and provider data accuracy go hand in hand. By acknowledging the interdependence of these two components and implementing practical strategies to enhance accuracy and adequacy, you can create a provider network that excels in meeting member needs. Now, go forth and conquer the day, one accurate data point at a time!
Discover how Quest Enterprise Services® (QES®) Accuracy can make a difference. Our comprehensive solutions enhance your process, offer better data transparency, reduce ghost networks, and improve compliance. Empower your organization to excel in the evolving healthcare landscape. Learn more about Quest Enterprise Services® (QES®) Accuracy today!
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