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Posted by on Jan 5, 2018 in Uncategorized | 0 comments

Pinning Down the Provider-Location Dilemma

Pinning Down the Provider-Location Dilemma

Our theme of data quality and directory accuracy continues. This time we are focusing on the most common provider directory error – inaccurate provider-locations. Location inaccuracies occur when a provider does not actively practice at a location where they are listed in a directory.

While inaccurate provider-locations cause headaches for members, they also cause problems for both network outreach efforts and data clean-up. When a provider is not at a given location, resources are wasted chasing down these “ghost” providers.

In today’s post, we are shining a light on what can be done to pin down the provider-location dilemma.


The Centers for Medicare & Medicaid Services (CMS) recently completed its first review of Medicare Advantage (MA) online provider directories. The review found that providers were not located at about 31% of the locations listed in directories. The 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 they could face fines or have enrollment frozen.[1]

According to information from SK&A, “physicians moved to new locations or practices, retired or passed away at a rate of 12% over the past year”.[2]

An assessment of data accuracy and volatility from Prime by Atlas revealed “the primary driver for volatile data accuracy is the change of the provider location. On average, about 24.8% of all directory issues are related to physical changes to the provider practice location”.[3]

Zelis analyzed hundreds of medical and dental provider directories and found the average directory lists about 8% of medical providers and 12% of dental providers at six or more locations, about 5% of providers at locations more than 200 miles apart, and as many as 1 in 4 providers with at least one location exclusive to that payer – that is, a practice location that is not found in any of the peer directories analyzed.

Maintaining the accuracy of provider data has been an ongoing struggle for many plans and CAQH states, “According to conservative estimates, the commercial healthcare industry spends at least $2.1 billion annually maintaining provider databases.”[4]

analyzing provider-location trends to improve accuracy

Zelis collects provider data for hundreds of networks on an ongoing basis. We are able to analyze that data to gather provider-level insights about the collective credentialing and validation efforts associated with those networks. Our analysis of network participation patterns for specific provider-locations enables us to separate the good data from the bad data to ensure outreach efforts are focused and efficient.

identifying old provider-locations

By tracking a provider over time at their locations across multiple health and dental plans, we can identify movement patterns. In other words, we can see when a provider-location begins to drop out of networks and identify the point in time where we are confident a location is old and no longer valid. Old locations that are no longer valid often get left in the data because no mechanism is in place to identify these old locations. Tracking trends in provider-locations across networks provides this mechanism.

identifying new provider-locations

We can also see when a provider has a new location. In the same way that we can see when a provider-location begins to drop out of networks, we can identify when a new provider-location begins to show up in networks. We can place higher-confidence that these new locations are valid.

360-degree provider view

The ability to look at provider data across multiple plans is key to clean-up efforts because it provides visibility to all of a provider‘s locations nationwide, regardless of network affiliation. This 360-degree view of a provider allows for the identification of non-par locations for a provider associated with a specific payer.

identifying out-of-network provider-locations

Even when a plan knows a location is no longer valid, there is often resistance to removing old provider-locations unless a new location can be added for fear of negatively affecting accessibility and competitiveness. This means old locations sometimes remain in-network because no valid new location has been identified. It can be difficult to identify a new location, especially if the new location is in a different service area. The complete provider view means there is a mechanism for identifying these new, non-par locations.

outreach and clean-up

Using a plan with a provider in California as an example, the 360-degree provider view means we can see the provider has a new location in New York and other carriers are removing the California location to reflect the provider has moved.

Whether the provider movement is national, regional, or local, once non-par locations for in-network providers are identified, they can be used to fill gaps created by the earlier clean-up efforts, helping to maintain a network’s accessibility and competitiveness. This also eases the burden of repeatedly trying to outreach to a provider at an old location where they are no longer practicing.

the Zelis way: the secret to improving accuracy

known bad data

We often hear from clients that one of their biggest issues isn’t just identifying bad data, but keeping it out. Data from other sources (such as leased networks) are constantly being reloaded, and create the very real scenario where the same bad data is being consumed over and over again.

Zelis is capturing and tracking these known-bad-locations to improve data accuracy. After verification, the California provider-location discussed above is stored as a known-bad-location. Should it make its way back in to network data, it will be flagged, ensuring plans don’t have to repeat the costly effort of verifying and cleaning-up this provider-location again.

market view

Zelis has visibility to every piece of directory data available – right or wrong. This visibility allows us to provide a new and unique solution to address provider data quality and directory accuracy. Zelis’ payer clients can focus their provider verification energy on the least reliable information, allowing them to efficiently prioritize their outreach activity. Bad data is catalogued for future reference, so if it reappears it can be flagged without the need to re-verify. High-confidence, non-par practice locations are suggested for both outreach and gap-fill, and ongoing data quality assessments help you track your progress.


To learn more about the Zelis Provider360TM solution and how we can help you improve the data quality and accuracy of your provider directory, please contact


[1] CMS. Online Provider Directory Review Report.

[2] SK&A. Healthcare Provider Move Rates: Market Insights Report. October 2016.

[3] Prime by Atlas. Whitepaper: An Assessment of Data Accuracy and Volatility.

[4] CAQH & Manatt Health. Defining the Provider Data Dilemma.

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