250,000 Incorrect Provider Records Fixed Overnight

 

Enclarity Finds That 77% of Provider Records Contain Errors

 

The Challenge

 

Bad provider data is rightly called the "Achilles heel" of healthcare. Without accurate provider information, healthcare payers cannot manage their operations efficiently. Each year, payers lose as much as $26 billion because of the poor quality of their provider records. They lose this money through payment errors, fraud, returned mail, the cost of issuing new checks, paying additional postage and fines for paying sanctioned doctors. In addition, they also incur millions of dollars in administrative costs trying to fix the data, and processing provider record data errors manually instead of through auto-adjudication.

 

While health plans have tried many times to fix this problem, until recently, these attempts have been both costly and unsuccessful.

 

With Enclarity, one healthcare claims management company* found the way to protect its "Achilles heel." Recognizing that bad provider data impeded its ability to provide optimal results for its clients, the firm turned to Enclarity for a new solution that utilized Enclarity's sophisticated analytic science to solve this stubborn problem.

 

The Solution

 

Enclarity set to work using its ProviderPoint® hosted solution, which is powered by its proprietary AcuSync™ process. ProviderPoint contains the industry's most accurate Master Provider Referential Database - more than 140 million records from over 4 million licensed healthcare practitioners and facilities. Each of these records is verified by AcuSync's sophisticated analytics. With AcuSync, ProviderPoint can bridge between information to select the data that is accurate. From that point on, records are updated constantly so that correct, current and comprehensive provider information is available 24/7. ProviderPoint is offered through a secure, hosted Application Service Provider (ASP) so that there is no investment required to purchase or upgrade software.

 

The Results

 

• Enclarity initially anticipated that one of three records - approximately 35% - within the total universe of 331,463 eligible records would require updating. Instead, ProviderPoint discovered that 77% of the records contained incorrect or incomplete information and needed to be fixed.
• 37% of records required augmentation - correction of more than one data element such as incorrect addresses, incomplete phone numbers, names with expired licenses, inconsistencies between licenses and DEA numbers, or listings of deceased providers
• 11% of records were provider duplicates, with the same address and TIN (taxpayer identification number)
• 40% of records needed to have standardized addresses to be accurate and usable
• More than 10,000 records had last names beginning with the letter "X"
• Almost half of the records had no zip codes
• Less than 1% of records had phone numbers
• 27 physicians in the database were deceased

 

Within one day, ProviderPoint corrected these errors. As a result, providers receive payments rapidly and the company reduced its labor costs.

 

With its "Achilles heel" now protected, the company is realizing substantial savings through its operational efficiencies, customer satisfaction and enhanced fraud detection and decision support reporting.

 

* This case study is based upon information from an Enclarity client that requested anonymity.