For State Regulators

Everything you need to know about state regulations.

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Provider data changes quickly and can be problematic to maintain. Yet, your members depend on its accuracy to receive access to the care they need to lead healthy lives and avoid unnecessary, costly care. And, regulators need evidence that you’re providing the right level of network adequacy based on accurate information ensuring member access.

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According to The Centers for Medicare & Medicaid Services’ (CMS) third-round review of Medicare Advantage Provider Directories, nearly 50% of Medicare Advantage Plans have between 30% to 60% inaccurate data. Think of it another way…members seeking provider information receive the correct data (i.e., the correct phone number, address, panel status) only 40% to 70% of the time. This exposes health plans to multiple risks including compliance, surprise medical bills, member dissatisfaction and lower Star Ratings. Ensuring consumers have adequate access to the care they need and can find that care with accurate directories is why regulators are starting to bring more attention to health networks where providers have excessive addresses or multiple unrelated specialties.

More than 50% of Medicate Advantage directories are 30% to 60% inaccurate.
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While accurate provider data is important to your members, removing inaccurate provider data from your network can have a drastic effect on your network adequacy. You need a system that helps you understand how managing your provider data accuracy will impact your network adequacy.  Only Quest Enterprise Services (QES) can provide you with the insights you need to measure, manage and monitor your network, so your members have the access they need to care.

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You need to understand the state of your data – the good, the bad and the ugly. Our Quest Enterprise Services (QES) Accuracy solution provides you with an Accuracy Index Score enabling you to analyze, report and act immediately on what’s right, wrong and missing from your provider data. You can quickly identify and address high-risk challenges, like invalid NPIs, OIG exclusions, excessive specialties or addresses and prioritize remediation efforts.

At the core of our Accuracy Services is Quest Analytics verified provider data.  With QES, we verify your data against trusted sources like the Office of Inspector General (OIG), National Plan and Provider Enumeration System (NPPES) and other proprietary sources. Our verified data sources meet stringent requirements and are focused on providing a comprehensive view of your provider directory data. We prioritize Federal and State-mandated data attributes to ensure you are seeing the information you need to maintain compliance.

Solve Your Provider Directory Accuracy Challenges Today

Our team is ready to help you address the challenges provider data presents. We want to help you take your member experiences to the next level and avoid regulatory risks, like audits, and meet the mandates around surprise billing.

Contact us today to book a strategy session to understand and provide guidance to limit your exposure.
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