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
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.
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.
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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