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What is Provider Data Validation – Are You in Compliance?

Curious what all the news is about? Here are the basics of Provider Data Validation: What it is and why it’s important.

Healthcare consumers rely on their insurers to provide comprehensive, current, and accurate information about in-network practitioners. It is critical that this information is accurate the first time a practitioner is added to the network, and that it is regularly validated to ensure continued accuracy.

Provider data validation is a crucial component of compliance. Over the past few years, we have seen the Centers for Medicare & Medicaid Services (CMS) and state regulators shift their review process to require accurate information to be maintained in a health plan’s public directory. As someone who oversees the network, you want to have a strong process in place to easily maintain and monitor your provider data to ensure continued compliance. Let’s take a deeper dive to better understand the importance of provider data validation for compliance and your members.

What is Provider Data Validation?

Provider data validation (sometimes referred to as provider data verification or attestation) is a process where health plans confirm each participating provider’s contact and other information displayed in the public provider directory is correct or incorrect.

The goal is to update and maintain their provider data to prevent incorrect provider information from having negative downstream effects.

Provider data validation helps ensure key information about the practitioner is accurate. This information can include:

  • Digital Contact Information
  • License Status
  • Hospital or Practice Group Affiliation
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While state and federal programs have varying requirements, they all have the same purpose: to help you ensure your members have access to care and at the same time, help your members receive care in a timely manner.

To protect consumers, CMS requires Medicare Advantage plans to routinely contact providers in their networks to validate or update the information for the public-facing directory. By maintaining an accurate database, you’re able to provide your members with an honest picture of which practitioners they can schedule an appointment with.

In addition to requesting health plans to get in touch with practitioners on a quarterly basis, network adequacy reviews are another way CMS monitors the compliance of a Medicare Advantage Organization (MAO). Health plans can submit their network for an annual review. Otherwise, every plan will at some point go through the Triennial Network Adequacy Review. This review happens every three years or when a triggering event occurs such as when a new application is created, a compliant about network access is filled or the health plan is expanding into a new service area. Those in violation face potential compliance or enforcement actions.

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Why is Provider Data Validation Important?

Actively managing the accuracy of provider data is critical to ensuring your members can access medical care. The directories that you provide are often the only source of information members rely on to locate providers that are within their network. Incorrect information within provider directories can lead to confusion and frustration for patients and providers.

Without consistently checking the information through provider data validation, inaccuracies can grow, and this can become a significant barrier in accessing care. For example, a member searches the network for a podiatry specialist and contacts the office only to find that they are not accepting new patients or may travel to an inaccurate address. In a worst-case scenario, an outdated listing may show an out-of-network provider as in-network, leading to a surprise billing charge for the member – which you or the practitioner now must fit the bill.

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Learn more about why inaccurate data is a barrier to care. READ NOW

How Do You Validate Provider Data?

Here Are Our Recommendations

Implementing a good system for provider data management can prevent inaccuracies later. Manually validating provider data can be a tireless administrative task. Partnering with a solutions-driven provider data management platform like Quest Enterprise Services can provide you with actionable insights into your network adequacy and provider data accuracy.

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