Preventive medicine for your PDQI Audit

 

A leading Blue Cross Blue Shield plan uses Enclarity ProviderPoint® to improve its healthcare provider information and PDQI score

 

Overview

 

The Provider Data Quality Index (PDQI) is a critical Blue Cross Blue Shield Association measurement standard with which all Blue plans must comply. The PDQI measures, among other things, the accuracy of provider information displayed in provider directories and Web sites. Each Blue plan’s provider records (that are housed in the Provider Data Repository for inter-plan use) are audited quarterly. The accuracy results are then compared with other Blue plans (by peer group). The Provider Data Audit, worth 45% of the overall PDQI, measures how useful provider information is to Blue plan members.

 

The Challenge

 

After several less than satisfactory PDQI audits, a leading Blue plan sent Enclarity a sample file containing 50 provider records. These were identified as having incorrect information when audited for provider data quality based on the Blue Cross Blue Shield Association guidelines. The Blue plan wanted to see if Enclarity could have helped it with those records, and thereby improve its PDQI score.

 

The Solution

 

We used our ProviderPoint® solution to standardize and match the providers in the file to the Enclarity Master Provider Referential Database, and to find correct, current information for those providers.

 

The Results

 

Based on the ProviderPoint run, using Enclarity’s ProviderPoint solution would have:

 

• Reduced the errors found in the audit by 76%
• Provided a basis to dispute another 20% of the findings, and
• Identified another 4% for research prior to the audit

 

The combination would have a significant positive effect on the plan’s PDQI score.
The results of the analysis were:

 

	Enclarity has provider info: Same as audit	Enclarity has provider info: Inactive provider	Enclarity has provider info: Same as the plan	Enclarity does not have provider info: Research required
Number	36	2	10	2
% of Total	72%	4%	20%	4%
Comments		These would have improved the score because they would not have been in the audited files	The audit result for these providers should be challenged	These could have been researched and fixed before the audit

 

Conclusion

 

Raising and maintaining the PDQI score to an acceptable, and beyond that, to an exemplary level, is a key priority for a Blue plan. But it’s an expensive effort to proactively validate all providers in a directory on a routine basis via phone, mail and manpower. Enclarity ProviderPoint can be a powerful solution for Blue plans, because it routinely reviews provider files against a robust source of continuously updated provider information. Quite simply, Enclarity ProviderPoint is the most cost-effective way to maintain the correct, current and comprehensive provider information you need to achieve and maintain exemplary PDQI scores.