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White Paper: Achieving Provider Data Quality in Your Directory

200+

Provider data currently includes more than 200 unique data elements.

96%

In a recent audit of 54 MAO’s directories, CMS issues 52 compliance actions, resulting in a 96% deficiency rate.

46%

46% of all providers had at least one deficiency.

45%

45% of all locations had at least one deficiency.

What is a Provider Directory?

A listing of healthcare professionals (providers) who have contracted with a health plan to provide care to its customers.

Directories are generally available to members on a health plan’s website, and they allow members to interactively search for providers that meet their criteria. In addition to just listing the providers, most directories will also give additional information to help their members select the proper provider and seek care from them.

What is Provider Data?

Defining provider data is difficult as standard definitions for data elements within the industry are lacking, and there are many stakeholders who define data elements differently based on their specific use of the data. A simple definition would be that provider data is information about individual providers, groups of providers, and institutions—who or what they are, how to access them, the services they provide, the health plan networks or products in which they participate, and other important attributes (currently more than 200 unique data elements.)

As the healthcare industry changes, the meaning of “provider” is also changing. Today, “provider” extends beyond physicians, hospitals, and allied health professionals to other practitioners and institutions who deliver or coordinate healthcare services, such as nurse practitioners, social workers, addiction counselors, community health centers, behavioral health agencies, and other community-based organizations. The extended complement of “providers” often addresses patients’ underlying social determinants of health, such as housing, transportation, access to healthy food, and employment. Provider data has historically focused on traditional clinicians, but, given the industry’s migration toward value-based care and its increasing reliance on other provider types, addressing today’s provider data challenges must include a more expansive definition of “provider.”