Provider directory accuracy is critical to ensuring consumers get the care they need from the right doctors. The challenge is the rate at which provider data changes and getting that information into the hands of members. Now regulatory bodies are demanding health insurers put processes in place that ensure the information they collect and publish to their member populations is current and complete. Updating mandatory data fields like address, acceptance of new patients, specialty, languages spoken and more can become overwhelming for a health plan – putting a strain on resources. LexisNexis explores where regulations stand, the nature of provider data and why maintaining it is a challenge, and a proven approach to managing your provider data and directories.

1. Navigating Provider Directory Accuracy Regulations
Webinar Presented by LexisNexis
February 24, 2016
This presentation cannot be duplicated or reproduced in part or in whole without written consent
from LexisNexis. Copyright © 2016 LexisNexis. All rights reserved.

2. Agenda
• Introductions
• Overview of where regulations stand
• Discussion around the challenge with maintaining provider data
• Explore a proven approach to managing provider information
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3. Speakers
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Josh Schoeller
VP, Client Engagement
LexisNexis Health Care
Tom Suk
Sr. Director, Provider Data Solutions
LexisNexis Health Care

4. Where the Rules and Regulations Stand
4Private & Confidential

5. Affordable Care Act Provider Directory Mandate
THE CHALLENGE:
Payers need support to
respond to evolving
regulations—or face penalties
Confidential and Proprietary 5

6. What is driving this Directory Accuracy Need?
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Simply Put: Inaccuracies have caused patients
to be billed for costly out-of-network charges
“Now that people have choices and can shop
between plans, provider directories take on a much
more important role,” said Anthony Wright,
executive director of Health Access California, a
health care consumer advocacy group. “We don’t
allow grocery stores to sell products with inaccurate
food labeling. ... We can’t have a functioning
insurance market if consumers don’t know what they
are buying.”2
Sources:
1 http://www.sacbee.com/news/local/health-and-medicine/healthy-choices/article42775785.html#storylink=cpy
2 http://www.sacbee.com/news/local/health-and-medicine/healthy-choices/article42775785.html#storylink=cpy
One major payer has already paid more
than $38 million in refunds to affected
patients1

7. Sources:
1 https://www.cms.gov/CCIIO/Resources/Regulations-and-Guidance/Downloads/2016-Letter-to-Issuers-2-20-2015-R.pdf
2 11/13/15 CMS memo, subject "Provider Directory Requirements - Update"
Qualified Health Plans (QHPs) and
Stand-Alone Dental Plans (SADP)
requirements1
Medicare Advantage, Medicare-Medicaid
Plans, Section 1876 Cost Plans, Prescription
Drug Plan Sponsors 2
Electronic provider directories updated
monthly
Update directories at least every 30 days
Directories must note whether provider is
currently accepting new patients
Conduct quarterly outreach to contracted providers
to ensure
Other provider directory elements must
include: provider name, location, contact
information, specialty, group affiliations
Directories must note whether provider is currently
accepting new patients
Other provider directory elements must include:
provider name, location, contact information,
specialty, network participation
CMS is Pushing for Provider Directory Accuracy
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8. Non-compliance can be Costly
1 Kaiser Health News, March 9, 2015
http://khn.org/news/health-exchange-medicare-advantage-plans-must-keep-updated-doctor-directories-in-2016/
Inaccuracies in the
Medicare Advantage directories
may trigger penalties of up to
$25,000/day/beneficiary
or bans on new enrollment
and marketing1
The federal exchange plans
could face penalties up to
$100/day/beneficiary
for problems in
their directories1
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9. New State Rules for Provider Data Accuracy
All but 12 states have adopted specific provider directory requirements for some types of state
health plans
Roughly half of all states specify updates are necessary, most noting the frequency of updates
In addition to Medicare Advantage plans, four states—CA, MD, NJ, VT—and DC require proactive
verification of provider directory elements
California recently enacted SB137, which requires that the plan:
• Investigate any reported inaccuracies within the provider directory within 30 days
• Review and update the entire provider directory by contacting all contracted providers for
verification at least annually
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10. Additional Legislative Changes at Both the State and Federal
Levels are Expected
Source: http://www.naic.org/store/free/MDL-74.pdf
Electronic provider directories
be updated at least monthly
Plans should consider contacting participating providers
who have not submitted a claims within 6 months in
order to confirm participation
Periodic audit of a sample of the
provider directory to verify accuracy
Directories must note whether provider
is currently accepting new patients
Other provider directory elements must include:
provider name, location, contact information, provider
gender, affiliations, specialty and languages spoken
National
Association of
Insurance
Commissioners
(NAIC) released
their
recommendations
for provider
directory rules
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11. Poling Question 1: How is your organization addressing these new
mandates?
• Using internal solution
• Working with a vendor
• Not currently acting, waiting for further clarity on regulations
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12. The Provider Data Challenge
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13. 0%
50%
100%
3 6 9 12 15 18
Bad Good
Provider demographic data quality degrades rapidly
• Human errors in data entry
• Multi-channel delivery of incoming transactions with errors/omissions
• Data integration challenges across data sources/organizational silos
• 2.4% of provider demographics change each month
• 30% of doctors change affiliations each year
• 5% of doctors change status each year
Provider Data is Changing all the Time
The provider universe
is always changing
The pace of business
leads to additional
inaccuracies
Months
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14. How Much Does Data Really Change in a Week?
• 33,000 primary addresses
• 3,300 names
• 1,750 phones
• 1,500 fax numbers
In the time we spent on this slide,
your provider data went out of date.
• 86,000 state license expirations
• 17,000 state license statuses
• 7,000 Qualifiers
• 1,000 DEA numbers
How do you keep your
provider data current?
How do you know if
providers are in good status?
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15. Significant errors in payers’ files
Quality Problem Average
% duplicate records 8.56%
% missing or bad phone numbers 23.56%
% bad addresses 18.26%
% sanctioned providers 2.49%
% retired providers 0.56%
% deceased providers 0.71%
Based on over 200 representative client network files (2014, 2015)
15Confidential and Proprietary
On Average, Payers in the U.S. are Between 55% and 70% Accurate
on Critical Directory Fields
Access Problem Average
% of providers reporting not participating /
accepting new patients
29.69% -
9.27%
Based Jan 2016 verification results to date across plans

16. What are Providers Thinking?
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17. Why is Updating Provider Directories so Hard?
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Provider
data
systems are
vast,
dispersed
and not
integrated
The
landscape is
constantly
changing
The
insurance
industry is
filled with
complexity
1 2 3

18. A Proven Approach
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19. What is the Best Way to Fix this Problem?
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“Baseline” your provider directory
Make it easy for a provider to
attest
Allow a provider to attest for
multiple payers and network plans
Monitor your directory population
Employ the right technology
• Cleanse your directory for de-dups, purge
outdated and obsolete information (i.e.
Deceased physicians)
• Assign a persistent ID (not just NPI) to each
provider so that subsequent information
changes can quickly be applied
• With the ability to process data quickly to
ensure timely updates
• Check your directory for changes as changes
are discovered for the provider (i.e., new
locations, detect new Medicare claims
activity, flag no Medicare activity, etc.)
• Allow multiple ways for a the provider or
office manager to attest their information
through a channel that they prefer
• A comprehensive, single approach where a
provider can be contacted once to attest for
multiple payers is critical

20. A Complete Solution Requires 5 Critical Components
• Network (provider files)
• Plan Participation (under contract)
• Contributed Claims
Conducts campaign outreach, including email, fax, call, direct mail
• Leverages > 2,000 sources to build the “best” view of a provider
• Covers more than 8.5M providers
Provider Data
MasterFile
Multi-Channel
Outreach and
Data Stewards
Payer
Consortium
• Simple enablement tool for streamlined provider self-attestation
• Internal – could enhance existing app (Calling App, Feedback App)
• External – build and/or partner with vendors Provider Portal
Ongoing monitoring of plan activity and tracking recency/frequency
Claims Data
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21. Sourcing Components: A Contributory Model
Payer
Consortium
Provider Network Files
Enable triggered validation of new locations
Reduce latency
Network / Product Tags
Enable dynamic selection of applicable
networks for validation
Direct Client Feedback Loop
Profile updates leverages across payers
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22. Poling Question2: How willing would your organization be to
participating in a consortium?
• Very likely – understand the value
• Possibly – need to understand the benefits more clearly
• Not at all
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23. Sourcing Components: Master Provider Database
Provider Data
MasterFile
Data Sources, Advanced Analytics, Verification
• Continuously updated profiles
• Authority and transactional sources used
so each attribute is accurate
• Analytic models target calls to those
most likely to have changed
Sophisticated Algorithms
Maximize record matching while limiting
false positives
Customization, Health Care Expertise
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24. Sourcing Components: Claims Enabled Near Real-Time Monitoring
Claims Data
Leverage Transactional Data Stream to
Monitor Latency and Reduce Risk
Monitor providers at practice locations and
correlated billing entities
Alert to new locations and provider changes
Track recency and frequency
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25. Sourcing Components: Leveraging Current Provider Touchpoints
Provider Portal
Customized Portal for Directed Data Capture
Dynamically serves up required verification:
• Demographics
• Network/product participation
• Ability to customize for incremental access
required elements
Open API Connection for Existing and
Industry Portals
Leverage existing touchpoints
Enablement of existing system(s) with
augmented external data
• Capture new touchpoints
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26. Multi-Channel
Outreach and
Data Stewards
Sourcing Components: Multi-Channel Outreach and Data Capture
Enable Scalable Direct Outreach Verification
Phone:
• Leverage U.S.-based and/or overseas
capabilities
Triggered based on tracked verification
requirements and external triggers to
optimize accuracy
Alternative contact mediums to maximize
responses:
• Phone, fax, email, portal, a web app
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27. Directory
Accuracy
Competing
objectives
require a
complete
and balanced
solution
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Compliance: A balancing act for the payer
Network
Adequacy
Medical
Loss Ratio
The Challenge
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28. For More Information
Josh Schoeller
VP, Client Engagement
O: 678.694.2004
Josh.Schoeller@lexisnexis.com
Linkedin.com/company/lexisnexis-risk-solutions
Youtube.com/user/lexisnexisnetwork
Twitter.com/lexisnexisrisk
Facebook.com/lexisnexisrisk
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This presentation cannot be duplicated or reproduced in part or in whole without written consent
from LexisNexis. Copyright © 2016 LexisNexis. All rights reserved.