No More Dead Doctors in Provider Directories

 

50% Error Rate in Health Plan's Provider Data Corrected by Enclarity ProviderPoint®

 

The Challenge

 

A regional health plan* in the Southeastern United States recognized that outdated provider information was costing them money and sabotaging efficient operations. Because there seemed to be no easy answer to this problem, the health plan manually "scrubbed" its provider files several times a year by deleting duplicates and fixing other errors in the records, such as removing deceased doctors and updating addresses. Unfortunately, this labor-intensive process was time-consuming, costly and ultimately, ineffective. As soon as one record was corrected, another became outdated.

 

Despite these efforts, the health plan continued to make payments to incorrect addresses, re-issue checks returned as "undeliverable" at a cost of approximately $20 per transaction, pay fines for making payments to sanctioned doctors, and frustrate members with outdated and inaccurate provider directories.

 

The Solution

 

As assessing both internal and external options, the health plan chose Enclarity to provide it with correct, current and comprehensive provider information. By combining sophisticated analytic science with deep understanding of the needs of the healthcare industry, Enclarity has developed a solution that gives healthcare payers the accurate provider demographic information they need for operational excellence.

 

In September 2005, Enclarity scrubbed the health plan's provider data files in just one day, using its ProviderPoint® hosted solution. ProviderPoint utilizes the industry's most accurate Master Provider Referential Database of more than 140 million records from over 4 million licensed healthcare practitioners and facilities. The Master Provider Referential Database is constantly updated and evaluated for accuracy by sophisticated analytic science. Once the data is cleaned, augmented and ehanced, ProviderPoint keeps it accurate and up-to-date, constantly tracking any changes or updates.

 

The Results

 

Enclarity reviewed 101,565 records for the health plan. Typically, Enclarity's experience is that 35-40% of provider records contain errors and omissions. In this case, Enclarity found that 50% of the records required updating with ProviderPoint. For this health plan, ProviderPoint found:

 

• 310 of the physicians in the database were deceased
• 3% of records were provider duplicates - with the same address and taxpayer identification number (TIN)
• 29% of records needed address updates
• 21% of records needed augmentation of a variety of fields, including incorrect addresses, incomplete phone numbers, names with expired licenses, inconsistencies between licenses and DEA numbers

 

The health plan's new cleaned provider files give the plan numerous benefits, including:

 

• An accurate provider database that is constantly updated
• Reduced expenses through reducing re-issue check costs and processing costs of manual claims
• Improved efficiency through increased auto-adjudication of claims, network quality, reduction of customer and provider call volume and handle time, and improved outcome reporting and analysis
• Reduced risks of fraud, notification non-compliance, fines and penalties for paying sanctioned physicians or 1099 errors, and NPI non-compliance and integration costs
• Enhanced provider and member relationships through accurate online network information, reduced returned mail, and quick and accurate provider payment

 

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