In 2016 we saw new provider directory regulations from CMS and several states, including the particularly “toothy” SB-137 in California. The new rules are intended to hold health plans accountable for any inaccurate and/or incomplete information in their provider directories. The national conversation is focused intently on the consumer side. That is, bad information makes it difficult for patients to make educated decisions when they select plans and can lead to access issues down the road.

The consumer issues are real, but only scratch the surface of the overall provider data problems we face.

  • Health plans and provider groups struggle to keep each other up-to-date making communication more difficult and less efficient.
  • Even departments within the same organization have trouble staying in sync and that leads to all types of problems in our day-to-day operations.
  • Government and regulatory bodies are hindered in their efforts to ensure appropriate access and coverage in our health plans.

When you put this all together you’ll begin to see why I call provider directories the ultimate death by paper-cut in healthcare. This is not as simple as it sounds.

Kicking-off the Provider Directory Series

Over the next 6-8 weeks The #HCBiz Show! will be focused on the provider directory problem. We’ll talk with experts who are dealing with this issue from all sides to understand what the issue is, why it exists today, and how we can fix it.

For background, you can check out our video conversation and the accompanying post from last year. You may also enjoy our breakdown of CMS’ first review of provider directory accuracy.

On this episode, co-hosts Don Lee and Shahid Shah give an overview of the issues and talk about the upcoming series. You’ll hear:

  • Lessons learned from our Infection Prevention and Control Series (1:05)
  • The difference between being Accountable and Responsible and how that can predict a solution’s success or failure very early on (2:42)
  • What is the Provider Directory issue? (9:15)
  • Why narrow networks require accuracy and adequacy (11:30)
  • Why half of the nation’s health plans would be fined if CMS implemented them today (14:00)
  • How inaccurate provider directories impact patients (15:00)
  • How the fines are making someone accountable for the first time (18:00)
  • Why it’s hard to keep just 15-20 basic pieces of information up-to-date (19:00)
  • How the need for health plans to let patients understand their narrow networks conflicts with their desire to keep their competitors in the dark (21:20)
  • How the bad data affects health plans internal day-to-day operations (22:20)
  • What can we learn from the internet’s Domain Name System (DNS) (25:50)
  • Who is responsible vs. who is accountable (26:40)
  • How are provider groups and health systems impacted by bad provider data (27:25)
  • How organizations like the AHIP Innovation Lab can help bring industry leaders together on problems like this (28:40)
  • Why it’s important to apply accountability at the right “height” within an organization (30:24)
  • How a federated solution might work at the national level (34:00)
  • How to enable collaboration in a competitive market (38:20)
  • Why it makes sense that the accountability is being placed on the health plans today (40:25)
Listen on Google Play Music

Or, listen right here:

Prefer to read it? Download the full transcription as a PDF.


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