Availity Blog

Top 5 Provider Complaints About Payer Requests for Risk and Quality Data


5.02.2016 by SUSAN BELLILE – Principal, Health Plan Risk & Quality


Payers need information about the population of members in their health plans to predict and track healthcare costs, and to comply with regulatory requirements for risk adjustment and quality assessment. The latter is particularly important for members in Medicare Advantage, Medicaid managed care and Affordable Care Act (ACA) plans. Most providers understand this, but as health plan information needs expand, so does the volume of requests they receive for assessments, attestations, and medical record documentation.

To better understand how these requests affect providers, Availity hosted discussions with some of the many providers in our nationwide network. Here are their top five complaints about the current process, along with suggestions on how to improve it.

1. It is a manual process outside of their workflow, and it’s difficult to track.

Providers submit claims and check eligibility and benefits online. Why can’t payer requests for risk and quality information also be managed online, using existing web-based connections between payers and providers?

2. I already provided you [the payer] with this information.

Within a payer organization, many departments request information from providers, including risk, quality, audit, and care management. Using one coordinated communication channel can reduce redundant data requests. Monitoring claims as they are submitted can also reduce requests for information that can be captured from the recent claim, such as patient conditions.

3. The provider information or association of this member with a provider is incorrect.

A number of initiatives are underway to improve the accuracy and consistency of payers’ information about providers. However, provider offices still receive too many requests related to physicians who are no longer in the practice, or for members who are no longer patients of that provider. Integrated functionality that enables providers to update demographic information—and communicate the status of their relationship to specific members—can help improve data quality.

4. It takes too much time.

Pre-populated forms can streamline data entry for providers by allowing them to verify existing information and complete what is missing. Online tools should be designed to present questions specific to that member based on variables such as age, gender, conditions, and plan type (e.g. Medicare Advantage, Medicaid, or ACA).

5. Every payer has a different process.

CMS and NCQA standards define much of the risk and quality information that is requested by each payer. Just as clearinghouses facilitate one process for submitting claims to multiple payers, risk and quality gateways can provide one process for submitting risk adjustment and quality measurement information that is requested by multiple payers.

Risk adjustment, quality reporting, and the movement toward value-based care models will continue to expand the scope of information sharing between payers and providers. Payers can reduce “provider abrasion” by leveraging existing online communication channels.

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