Top Challenges in Provider Data Management

While health plan provider directory inaccuracies have been at the forefront of the news, regulatory agencies, and consumer protection agencies, the directories are only the tip of the iceberg in how difficult provider data management is for health plans. Plans continue to gather information on providers in a multitude of ways and from a variety of functional areas, continue to create conflicting repositories of provider data, and thus continue to face the painstaking and almost always manual validation of provider information.

As we have worked with clients through Medicare Advantage service area expansion applications, exception process, and the upcoming bid filing, we have repeatedly seen plans faced with spending hours having their provider teams manually tracking down providers and correcting provider information in order to prepare accurate Health Services Delivery (HSD) tables and exception request forms. A few of the top challenges found have been the following:

  • The CMS Provider Supply File: Centers for Medicare & Medicaid Services (CMS) offered an olive branch in providing the list of servicing providers they use as a source when reviewing a plan’s provider network. Plans, however, had a difficult time validating the provider information they had internally against the Provider Supply File and using it to their advantage in preparing network exceptions.
  • Inter-plan relationships and provider sharing between lines of business oftentimes had unclear boundaries on which providers could be used or were contracted for the various products at hand.
  • When reviewing an overall coverage area, they appeared complete; when broken out into potential provider-sponsored plan (PSP) offerings, provider gaps were found.

With all three of these situations, plans were affected by a lack of time to mitigate the compliance risk facing their networks. As health plans move forward in finding ways to keep their directories in compliance, we challenge you to take a step back and look at provider data management in a holistic manner to solving directory, credentialing, and network adequacy issues, improving care management with better data management on what your network partners offer, improving relationships with your Star Ratings and risk adjustment vendors, and ensuring a strong network management program. With a spotlight on network management across all government-sponsored programs, let Gorman Health Group be your partner in designing a provider data management system that will meet your needs.



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Elena Martin
Elena Martin

Elena Martin is Senior Director of Provider Strategies at Gorman Health Group (GHG). In this role, she has acted as Project Manager for numerous network expansion projects on a national level and has been a key consultant in Accountable Care Organization (ACO) and End-Stage Renal Disease Seamless Care Organizations (ESCO) application and development.

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