What do NCQA and PDQI have in common? The answer: they are important industry designated benchmarks and measurements that include provider information quality. And each one can determine compliance to industry standards. Combine those industry benchmarks with state and federal requirements for appeals, access to care, prompt payment rules and audits, a health care payer has a lot to comply with. How well the quality of your provider file adheres to these standards can directly impact the profitability of your business. Poor provider data quality can result in lost revenue, penalties and late payment interest, branding issues resulting from negative publicity and if your business is publicly traded, declining stock prices. In addition, poor provider data quality can be the cause missing state and federal regulations related to appeals, and late payment interest.

 

NCQA Accreditation (National Committee for Quality Assurance) is considered table stakes for most healthcare payers. Missing this seal of approval can have a very negative impact when dealing with clients and prospective new sales. NCQA has measures associated with access, service and provider qualifications. Failing to have the correct information about a provider risks member access, service issues and even if a provider should be a part of a payer's network.

 

If you're a Blue Cross Blue Shield Association affiliate, receiving a strong PDQI (Provider Data Quality Index) score is a critical association objective and impacts Blue plan rankings and Blue Card processing. A key driving factor in attaining consistent quarterly results on the PDQI report card is the success of the provider data audit for the PDQI report. Failure to have the correct phone number or address of a provider will negatively impact the results and drive down overall PDQI scores.

 

Regulatory requirements related to appeals acknowledgements, late payment interest, access to care, even HIPAA, rely on accurate provider information in order to be successfully achieved. The wrong provider phone number or address or lack of sanction information, to name a few, will drive delays in delivery of acknowledgment letters, claim payments, and negatively impact access to care. That's why keeping your provider files accurate and up-to-date is so important. If only there were an advanced, automated and intelligent way to standardize, clean and augment incorrect and outdated provider information, and keep it that way.

 

The good news is that there is such a solution: Enclarity ProviderPoint®. With ProviderPoint, you can transform your provider file's accuracy. By investing in an ongoing program to cleanse incorrect, outdated and missing provider information from your files, along with a continual process to keep your provider files correct and current, the resulting good provider information quality can dramatically improve your profitability and regulatory compliance, and the standing of your business among your peers.

 

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