Availity Blog

Provider Directories and the Audit Challenge


4.16.2018 By Mark Martin, Director, Payer Solutions - Provider Data Management


CMS recently issued a report on provider directories that identified three underlying challenges health plans face. In the first blog on this topic, I discussed the issue of contractual versus resource constraints. This blog covers the second, which is the lack of internal audits by health plans to verify provider information.

The second problem CMS identified in its report on provider directories was a lack of internal audits by health plans to verify provider information. The report faulted health plans for outsourcing the audit process, stating “Medicare Advantage Organizations (MAOs) placed full faith in credentialing services and vendor support, and even in provider responses...” and “if MAOs had implemented routine oversight of their processes for data validation, errors in the provider directory would have become apparent.”

A good audit process is critical to maintaining accurate data because it exposes the root causes of poor information, making them easier to eliminate. To create a closed-loop, internal audit protocol, health plans need to first address how data in provider directories is populated and maintained.

Audit criteria doesn’t match the source data

In the first blog I noted that provider directories are primarily based on contract information, which does not always reflect what’s happening at the local provider office. The challenge for health plans is that CMS conducts its provider directory audits by calling that local office and asking the staff there to validate the information. Until health plans find a way to reconcile the contract data vs. what’s actually happening in the provider office, audits—whether conducted by the plan or CMS—will continue to unearth problems.

Lack of context causes provider confusion

The CMS report notes that providers themselves are sometimes the source of inaccurate information. While this can happen for a variety of reasons, it’s often because providers don’t understand the context of the information they are being asked for. The provider is supplying information that is technically accurate, but incorrect for the purposes of an audit.

A good example of this is a provider phone number. For a provider directory audit, CMS is verifying that the phone number in the directory is the one patients can call to request an appointment. But even the smallest provider office has several different phone numbers, so health plans must be specific when asking providers to provide or confirm information. For example, “Please confirm that xxx-xxx-xxxx is the number patients call to request an appointment,” would produce better quality results than asking “Is this the right number for your office?” If a request is vague, the answer will depend on how the respondent interprets it.

A comprehensive approach to provider directory data

As CMS notes, it’s important for health plans to more closely monitor provider directories to ensure the information is correct; internal audits are just one part of a comprehensive approach to provider directory accuracy. Health plans must evaluate all of the processes that influence the gathering and maintenance of provider directory data.

Context of questions is important to get the most accurate information. Availity is improving the quality of provider directory information by providing a centralized source for accurate provider data and continually evaluating how we ask for key information like phone numbers and addresses. To learn more about the work Availity is doing around provider directory data accuracy, visit Provider Data Management.

This is the second in a three-part series on the state of provider directories. Visit CMS report: 3 problems plaguing provider directories to read the first.


Share a link

play video