Let’s set the scene.

Sarah, a diligent healthcare broker, is helping her client John navigate the complexities of enrolling in a new health plan.

John has specific needs: his long-time physician, Dr. Jeffery Lambert, must be in-network, as he relies on him for ongoing care. Sarah turns to her provider directory, confident that it will guide them accurately.

But what if the data is outdated or incorrect?

Sarah’s confidence wavers, and instead of smoothly assisting John, she spends precious hours cross-checking information across various carrier websites.

This scenario underscores the critical importance of reliable provider directory data. Here’s how you can ensure it.

Obtaining the Data

Direct Carrier Handoff: Real-Time Accuracy

The journey to accurate data begins with how you obtain it.

Direct carrier handoffs are the gold standard, providing frequent updates—often daily or weekly—from the carriers themselves. This real-time data ensures that the information Sarah accesses is current and reliable.

During critical periods like open enrollment, when multiple versions of a network may exist, having the correct start and term dates for providers is essential. This means Sarah can confidently tell John whether Dr. Lambert will be in-network when his new plan starts, not just if she is in-network today.

Third-Party Sources: Filling the Gaps

Sarah can also tap into third-party sources like the National Plan and Provider Enumeration System (NPPES) for supplementary data.

NPPES provides address and specialty information, but it’s self-reported and not always up to date. Physicians often fail to update their status when they change addresses, retire, or pass away, so while NPPES is a valuable tool, it must be used in conjunction with more current data sources.

Presenting the Data

Once you have accurate data, presenting it clearly and concisely is paramount. Sarah and her clients, like John, benefit from a streamlined, user-friendly experience.

Clean Data Presentation: Building Trust

Consider the difference between provider search experiences:

In the photo above we see two options.

Option 1 represents a provider search using direct carrier handoff. When searching, two addresses appear. One is recognized as a high confidence address, while the other is listed as a possible address. The search then goes on to detail that the high confidence address is indeed correct and current, while the possible address is a recently closed office.

Simply put, option 1 presents a unified, accurate view, making it easy for Sarah to confirm that Dr. Lambert is indeed in-network for John’s chosen plan. This clarity builds trust in the provider directory, saving time and reducing frustration.

Option 2, which shows three different, but all-together lacking, websites, however, is a different story.

Showing a provider search that uses harvested data and MRFs, the websites in option 2 show both office locations as active, as well as another additional location due to a transposed number typo that wasn’t caught. But it doesn’t stop there. Option 2 not only shows the incorrect location once but multiple times (once with a suite and once without).

In other words, the websites used in option 2 are convoluted with duplicate records, creating confusion and distrust in the systems used, and no real answer for Sarah and John’s in-network provider search.

The Don’ts

To truly enhance the reliability of provider directories, it’s crucial to consider the limitations of certain data sources (especially those that you currently use) and the importance of diversifying data collection methods.

Here are some key considerations to avoid common pitfalls:

  1. Avoid Sole Reliance on Monthly Updates of Provider Directory Machine-Readable Files (MRFs): While MRFs are a common source, they may not always reflect the most current provider data due to processing delays. It’s essential to supplement this information with more timely updates directly from carriers.
  1. Be Cautious with Regular Web Scraping of Online Directories: Solely depending on data from quarterly or monthly web scraping can lead to inaccuracies. Direct data sources generally provide more reliable and up-to-date information.
  1. Use Claims Data with Caution: While claims data can offer insights into provider activities, it’s important to consider its timeliness and accuracy. The processing time for claims can introduce significant delays, and recently submitted claims may not accurately reflect a provider’s current practice location or network status.
  1. Neglect Carrier Relationships: Avoid overlooking the importance of strong relationships with carriers. Strong partnerships are essential for accessing complete, timely, and accurate data, which is crucial for the reliability of your provider directory.

By addressing these issues, John can be provided with accurate and reliable information. This approach not only streamlines the process but also builds trust in the provider directory, making it a dependable resource for making informed healthcare decisions.

Data Processes: Behind the Scenes

Navigating healthcare data requires a keen eye for detail and a commitment to precision. Behind the scenes of reliable provider directories lies a robust process.

Here’s a glimpse into how a few essential tasks transform chaotic data into a streamlined, trustworthy resource:

Standardization

Standardizing names, addresses, and specialties is the first step in ensuring data accuracy. By cleaning and correcting discrepancies, you ensure consistency across all records.

Matching and Aggregation

Next, you match and aggregate data. This involves linking different records that refer to the same provider, even if there are slight variations (e.g., Street vs. St. vs. Str.). The result is a single, accurate record that consolidates all relevant information, providing a clear and reliable source of truth.

By following these rigorous data processes, you can ensure that brokers like Sarah can always provide clients like John with the most accurate, up-to-date information, ensuring they receive the care they need without unnecessary hassle. Reliable data for provider directories not only empowers brokers and agents but also enhances the entire healthcare decision-making process for beneficiaries and members.

The wrap up

Data isn’t just numbers; it’s the bedrock of strategy, the blueprint for innovation, and your shield against risk. For brokerages and FMOs, the accuracy of provider directories isn’t just important—it’s vital, shaping the very core of your operations and your path to success.

But mastering this challenge demands more than diligence; it requires a bold, proactive strategy. Embrace the power of direct carrier supplied data to anchor your decisions in reliability and stability. By doing so, you can mitigate risks, improve operational efficiency, and better serve your customers.

Interested in how Zelis can transform your provider directory into a beacon of trust and efficiency? Discover the Zelis difference.