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Posted by on Aug 1, 2017 in Uncategorized | 0 comments

Dental Data Quality & Directory Accuracy

Dental Data Quality & Directory Accuracy

introduction

Directory data accuracy is in the spotlight now more than ever. In the dental industry, a major pain point is network inflation by access points as carriers race to market the best network access for their members. We hear a lot of complaints from our dental customers about this issue but maintaining accurate provider directories is a complex and resource intensive task.

The Centers for Medicare & Medicaid Services (CMS) recently completed its first review of Medicare Advantage (MA) online provider directories. The review found providers were not located at about 31% of the locations listed in directories.[1] Retired and deceased providers were also found in many directories.

CMS identified a “general lack of internal audit and testing of directory accuracy” as a contributing factor to directory inaccuracies. Issuers with high rates of errors were warned that they could face fines or have enrollment frozen.

The accuracy issue isn’t limited to MA plans. Iowa’s Medicaid program has come under attack over directory concerns[2], as well as Marketplace and commercial plans, which have seen their share of directory complaints.[3]

Recently, several states have proposed or passed legislation implementing more stringent directory requirements for medical and dental plans.

In Georgia, Senate Bill 302[4] requires insurers to maintain accurate provider directories and at least annually audit a portion of their provider directory for accuracy. Illinois, has proposed language that a provider-location only be displayed in an online directory if a provider has been paid a claim at that address within the last three months.

If other states follow suit, it will be imperative that managed care organizations, both dental and medical, find a cost-effective solution to clean up their online directories to provide the most up-to-date information to their members.

what we did

Zelis is in a unique position to help improve directory accuracy. We collect data from hundreds of payers for thousands of networks on an ongoing basis. This allows us to curate a robust provider database containing information on nearly every dental and medical provider in the United States. Using this data, we can identify providers with demographic inconsistencies across payers and networks that payers are not able to identify in their provider data alone. We then produce lists of suspect providers for our clients who can begin primary verification on this targeted list of providers.

This Insights Brief contains high-level views of several provider data quality tests for seven national DPPO networks.

The first test produced a list providers who have access points that are more than 200 miles apart. This could indicate the provider has recently moved and the network may have an old address listed for this provider.

The second test was aimed at finding how prevalent the issue of inflated access points is by flagging providers that have six or more access points in their respective directories. (It should be noted when performing this analysis for our customers this access point threshold can be tailored to their specifications.)

The third test compares providers against the NPI inactive list.

 

why we did this

Our goal is to ensure our clients have visibility into how their provider data is being viewed in the market. Data quality and accuracy are key to a member’s ability to access quality care in a timely manner. We constantly work to innovate in the provider network space and lead our clients into the future of healthcare. We give our clients the information and tools they need to adapt quickly to the changing healthcare landscape.

The Zelis Directory Health Check takes a closer look at the directory accuracy issue challenging all dental plans today and what we at Zelis can do to help our customers mitigate these issues and solve an industry-wide issue.

the results

providers that have relocated

Networks B and C were the largest offenders, with 7.9% of directory providers (8,641 total providers) and 7.8% of directory providers (7,735 total providers) respectively, when it came to listing providers at access points that are more than 200 miles apart. Network F fared the best with only 5.0% (4,796 total providers) of providers shown at access points more than 200 miles apart.

over-stated addresses

The results of this test confirmed our suspicion that access point inflation is a major issue in the dental industry. Again, Network B (15.2%, 16,674 total providers) and Network C (16.5%, 16,364 total providers) had the most providers in their directories at six or more access points.

While it is not impossible for a provider to practice at six or more locations, it is suspicious.

 

specific example

The image of Florida shows us a real example of a flagged provider from our second test, providers with over-stated addresses. The provider, in our records, has 118 locations around the state, with all of those locations in network B. Zelis Network Analytics’ Address Confidence score tells us that there is a high confidence for the location in Pompano Beach, FL and our verification service confirmed the Pompano Beach location as the location where this provider practices. We can safely conclude there is a high pro

bability that the remaining locations are inaccurate, and can begin the data cleanup process.

This access-point inflation is a common occurrence in the dental space and is often the result of contracting patterns with Dental Service Organizations (DSO). Oftentimes, when a provider enters into a contract with a DSO, the contract requires that they be displayed at all locations that DSO has.  If a DSO has 100 offices in 10 different states they require the provider be listed at all 100 offices. An example like the provider above can easily happen if the DSO has any sort of multi-regional or national footprint.

NPI inactive providers

All networks have below 1%, but nonetheless, this can represent over one thousand total providers.

 

 

conclusions

By looking at the results of the three tests, we can clearly see trends in provider data quality across the selected networks. If we look at the percentage of total providers in each network, some networks appear to have more accurate data than others. For instance, network F has the one of lowest percentage of suspicious providers for each test performed, suggesting the data for providers in that network is of higher quality than the others. Conversely, network B consistently ranks among those with the highest percentage of suspicious providers flagged.

It is time for a fundamental shift in how we view dental networks. Displaying providers that practice at 10+ locations may seem good for dental plans in a competitive situation, but this practice presents a real danger of member confusion and dissatisfaction, surprise out-of-network bills, and it increasingly puts the plan at risk for regulatory action.

 

Beyond the Data – Research and Reporting

While raw data is certainly useful, the real value comes from what you do with that data.

The Zelis team is uniquely positioned to analyze that data from both a macro view and a micro view. With our in-depth research and analysis of relevant industry trends, you will have the best data and the best insights.

While it is clear that the healthcare industry is changing, most organizations don’t have the right resources or tools to examine the changing environment. Organizations need to gain an understanding of how these changes are being implemented by various industry participants to stay competitive and viable in this dynamic Industry. At Zelis, we are constantly monitoring the shifting landscape to provide industry stakeholders access to the most current research and analysis.

We will develop a custom deliverable, giving you access to market-specific insights that deliver actionable knowledge about your market.

 

For questions or to have your own customized analysis please contact insights@zelis.com.

Want to discuss in person? We will be at the NADP Converge conference in September. Stop by our booth or email us at sales.analytics@zelis.com to set up a time to chat.

 

Analysis conducted by Patrick Innes

[1] HealthAffairs. Secret Shoppers Find Access To Providers And Network Accuracy Lacking For Those In Marketplace And Commercial Plans. http://content.healthaffairs.org/content/35/7/1160.abstract?=right

[2] The Gazette. Opponents ask if Medicaid network is ready. http://www.thegazette.com/subject/news/health/opponents-ask-if-medicaid-network-is-ready-20160204

[3] HealthAffairs. Secret Shoppers Find Access To Providers And Network Accuracy Lacking For Those In Marketplace And Commercial Plans. http://content.healthaffairs.org/content/35/7/1160.abstract?=right

[4] Georgia Senate Bill 302 http://www.legis.ga.gov/Legislation/en-US/display/20152016/SB/302

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