Unverified Provider Data: The Hidden Costs and How to Solve Them

The Truth About Unverified Provider Data: The Hidden Costs and How to Solve Them

You’re probably aware of all the buzz surrounding provider data accuracy. And as someone who takes their job seriously, you probably think about this all the time. You might even be wondering:

  • How many of our providers haven’t attested to their information recently?
  • Just how disastrous can it be if we have providers who haven’t attested to their information?


Well, you’re not alone. In fact, we did the research and we’re here to share some eye-opening insights with you.

Video more your jam? Hear Scott Westover break it down.

If you prefer to listen, we’ve got you covered. Press play and let Scott Westover break down our insightful study for you in this video.

Quick Recap of the No Surprises Act

Before we dive into our investigation, let’s do a quick recap of the No Surprises Act. This little gem requires group health plans and health insurance issuers to verify their provider directory data at least every 90 days. On top of that, you must have a defendable and documented process for provider outreach, attestations, and data management. You know how it goes, you have to show your work. 📋

No Delays Allowed – If any providers or facilities fail to respond, and you can’t prove they’re actively seeing patients, they must be suppressed from the directory and network analysis. You’ll need to channel your inner detective before letting them back in.

💻🔎 Want more details? Head over to our article on Provider Data Management Tips to Successfully Meet the No Surprises Act to learn more about the requirements and how to establish a compliant provider data management process.

PSA: Provider Verification Timeframes May Vary

Ah, the wonderful world of provider network regulations. Just like the weather, provider verification timeframes may vary depending on the location of your services. Be sure to double-check your compliance and legal obligations. You’ve got this!

The Perils of Unverified Provider Data

Alright, let’s get back to the topic at hand. We focused our study on a New York health plan and honed in on primary care physicians in one county. Any primary care physician who hadn’t attested to their information in the last year was excluded from the network analysis. Here are the jaw-dropping results. 

Feeling the Impact: Three Reasons Why Provider Verification Matters

1) Longer Distance to Care

The Average Driving Distance to Care for PCPs Went from 4.2 Miles to 34.3 Miles: Time for a Road Trip?

Talk about a hike! Patients would have to travel eight times farther to access primary care services. That’s a serious inconvenience, especially when they need medical attention pronto. By verifying provider data, you can make sure patients have convenient access to care, minimizing travel time and maximizing their well-being.

2) Decreased PCP Availability

Primary Care Physician Availability Decreased by 90%: Do You See A Lack of Options?

Yikes! Without provider attestations, the availability of Primary Care Physicians took a nosedive. Imagine trying to find a Primary Care Physician when 90% of them are suddenly MIA. It’s like trying to find your keys in the Bermuda Triangle! By prioritizing provider attestation, you can ensure you stay active in contracting plenty of primary care options for your patients, with no shortage in sight.

3) Reduced Market Representation

Reduced Market Primary Care Physician Representation: What’s That About Network Strength?

Brace yourself for this one— the proportion of Market Primary Care Physicians dropped by a staggering 91%. Talk about a shake-up to the strength of your network and patient options. It’s like losing 91% of your retirement savings. By ensuring provider attestation, you can keep a diverse network of primary care physicians, giving patients choices on who to see for their healthcare needs.

Provider Data Accuracy Tips: Fewer Risks, More Solutions

Now, let’s talk about practical solutions. Here are five best practices to incorporate in your provider data accuracy strategy.

  • Tip 1: Establish a Solid Process 

To start, you’ll want to build a sturdy, rock-solid process for provider outreach, attestation, and data management. Document it, defend it, and let it be the shining beacon of your success. Show the world (or at least the regulators) that you’re tackling the provider verification task head-on.

  • Tip 2: Create a Communication Plan 

Communication is key. Create a well-thought-out communication plan with your contracted providers. Let them know they’re part of the provider data accuracy dream team. Add some friendly language to your provider contracts, agreeing on terms to stay in touch regarding verification timelines and updates. It’s all about teamwork!

  • Tip 3: Embrace Technology and Automation

Now, let’s talk tech! Use the dynamic trio of an enterprise provider network management solution, automation, and reliable vendors to streamline your provider verification process.  Provider verification is a massive task so why not get a little help from your friends?

  • Tip 4: Resolve Unverifiable Data Promptly 

Ah, the mystery of unverifiable data! Establish a quick and efficient process to crack that case and resolve it promptly. Need some expert guidance? Schedule a strategy session with our team. We’ll help you solve the mystery and get your data back on track.

  • Tip 5: Use Additional Data Insights 

Last but not least, let’s talk about using more data insights to uncover clues about provider activity. We’ve got some mind-blowing ways plans are doing this, and we’d love to share them with you. James Lamb is here to give you a quick overview in a video clip. Get ready to have your mind blown!

Provider Data Accuracy and Network Adequacy

It's All Connected

Remember, as you work on improving provider data accuracy you will experience shifts in network adequacy. Accuracy impacts adequacy and having a view of both will help you understand the relationship between the two. Make sure you have a process in place to measure, manage, and monitor network accuracy and network adequacy together.

So there you have it. Let’s get those provider attestations rolling and keep the healthcare machine running like a well-oiled engine. Cheers to accurate provider data and excellent patient care! Until next time, keep rocking the healthcare world!

More On Provider Data Accuracy and Network Adequacy

Stay up-to-date on the latest developments and best practices in provider data accuracy with these valuable resources! We’ve rounded up some of the most helpful articles on current network adequacy and provider data accuracy rules to help you navigate the changing landscape. Dive in now!

Proven Solutions for Your Provider Network Management

Looking to simplify your workload? Let Quest Analytics take on the heavy lifting! Our solutions and dedicated team specialize in provider data accuracy and provider network adequacy for various lines of businesses, including Medicare Advantage, Medicaid and Commercial. Schedule a strategy session today and see how we can help you every step of the way.

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