On this episode, the fourth in our ongoing Provider Directory Series, we continue to unravel the “why” behind provider directory inaccuracies. One major theme that’s emerged is that we have a context gap between health plans and providers. That is, even when we’re asking the right people at the right time, we might be asking the wrong questions.

Our guest, Ron Urwongse, a Senior Product Manager at CAQH, explains how adding a level of specificity to our questions can yield dramatically different results. For example, if you ask a provider if they work at an office, they may say yes even if there’s only a slight chance they ever will (i.e. to cover for a colleague). The tendency, Ron explains, is that providers play defense – they don’t want to have a claim denied if they ever do submit one from that office.

By adding some specificity to our questions, we could cut down on the confusion. How often do you work at this office? Or, do you accept new patients at this office? Are bound to yield more accurate results. These follow-on questions help the providers to understand what they are truly being asked. We can add even more context by making sure they know how the information is going to be used. Where do you bill from so that our billing department can process your claims properly? Where should our provider directory list you as accepting new patients?

Ron and I discuss this context issue and so much more, including:

  • What is provider data? (2:00)
  • Besides demographics, what else do we need to know about providers? (4:00)
  • In addition to patients, who else is affected by bad provider data? (5:30)
  • We’re spending billions of dollars managing provider directories. Why are they still broken? (8:15)
  • Is it fair to place accountability on the providers and put pressure on them to resolve this issue? (10:57)
  • What are the proposed penalties from CMS for Medicare Advantage plans whose directories fall out-of-date? (11:50)
  • Has anyone been fined yet? (12:10)
  • Do health plans do a good job of sharing provider information across departments within their own organization?  (12:10)
  • Why can’t I just go to NPPES? Why aren’t the doctors keeping their data updated? (15:00)
  • Why do providers (and their groups) report that they work at locations that they don’t work at? (17:37)
  • Why do providers feel that their data submissions fall into a black hole once submitted? (20:00)
  • The typical 5 -doctor practice has 12 contracts and each of them requires 140 data points. That’s 8,400 data points for a relatively small practice. (21:20)
  • Are the regulators being reasonable in their demands? (23:30)
  • How does contracting and reporting at the group-level cause problems for provider directories? (25:30)
  • Is there any reluctance to share because of security/privacy/competitive concerns? (29:15)
  • How does the expansion of the care team make this problem more complex? (31:40)
  • What’s happening on the solution side? (33:15)
  • How can we foster safe collaboration among industry competitors? (34:10)
  • A call to reduce provider burden, while simultaneously raising their accountability. (35:00)
  • What is the minimum necessary data set for provider directories? (38:30)
  • What is CAQH doing to solve the problem of bad provider data/inaccurate provider directories? (37:00)

I hope you enjoy it!

– Don Lee

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About Ron Urwongse and CAQH

Ron Urwongse is a Senior Product Manager at CAQH. Ron guides the cross-functional team responsible for CAQH ProView. Previously, he led product development and operations at Tyrula LLC, focusing on risk adjustment and quality improvement solutions in managed care. At Vecna Technologies, Ron served as a product manager. He also led the development of a billing solution for the Massachusetts Commonwealth Connector, the first state health insurance exchange website. Ron received his MBA from the MIT Sloan School of Management, Master’s Degree in Information Systems Management from Carnegie Mellon University, and B.S. degree in Information Systems from Carnegie Mellon University.

CAQH, a nonprofit alliance, is the leader in creating shared initiatives to streamline the business of healthcare. Through collaboration and innovation, CAQH accelerates the transformation of business processes, delivering value to providers, patients, and health plans.

  • COB Smart® quickly and accurately directs coordination of benefits processes.
  • EnrollHub® reduces costly paper checks with enrollment for electronic payments and electronic remittance advice.
  • CAQH ProView® eases the burden of provider data collection, maintenance, and distribution.
  • SanctionsTrack® delivers comprehensive, multi-state information on healthcare provider licensure disciplinary actions.
  • DirectAssure® helps health plans increase the accuracy of provider directories.
  • CAQH CORE® maximizes business efficiency and savings by developing and implementing federally mandated operating rules.
  • CAQH Index® benchmarks progress and helps optimize operations by tracking industry adoption of electronic administrative transactions.

Learn more:

CAQH Home: https://www.caqh.org/

Provider Data Action Alliance: http://CAQHProviderData.org

Provider Data Tools from CAQH: http://ProviderDataManagement.org

Defining Provider Data Whitepaper: https://www.caqh.org/about/defining-provider-data-white-paper

Twitter: @CAQH


Mentioned on the Show

JAMA: The Accuracy of Dermatology Network Physician Directories Posted by Medicare Advantage Health Plans in an Era of Narrow Networks

Health Affairs: Secret Shoppers Find Access To Providers And Network Accuracy Lacking For Those In Marketplace And Commercial Plans

CMS Online Provider Directory Review Report


About the Provider Directory Podcast Series

This episode is part of our ongoing Provider Directory series that aims to dissect the issue from all perspectives, including provider, payer, patient, and regulator. Our goal is to help facilitate an expanded national conversation that drives us towards an open, collaborative industry solution.

Check out all our Provider Directory posts and episodes here!


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