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Provider Directory Data Accuracy in CA Law's Crosshairs

Analysis  |  By  
   August 09, 2016

Inaccurate provider directories are a hurdle to consumers seeking healthcare, but a California law is pushing providers and technology professionals to make improvements.

Consumer frustration with inadequate provider directories may finally be getting the attention it deserves.

At next month's innovation-focused Health 2.0 conference, the Robert Wood Johnson Foundation and ProPublica will announce the $50,000 first-prize winner of their Finding the Right Provider Challenge.

The winner will demonstrate a tool letting consumers experience searching for and finding the right provider, considering factors such as cost, hours and location, participation with insurance plans, and feedback from other consumers.

Inaccurate Provider Lists A Major Barrier To Care, Study Finds

While such "carrot" incentives make progress, there are also some new sticks.

Late last year, CMS gained the authority to fine plans up to $25,000 per Medicare Advantage beneficiary for keeping inaccurate provider directories.

Then, last month, the state of California enacted SB 137, which requires all health plans in the state to keep their provider directories online and up-to-date – so much so that the bill requires a plan or insurer, at least weekly, to update its online provider directory, and at least quarterly, to update its printed provider directory.

Onus is on Provider

All of this is welcome news to one Los Angeles-area public health plan, L.A. Care. Many of its 2.1 million members are either in Medi-Cal, California's version of Medicaid, or Covered California, the state's health insurance exchange. SB 137 helps those members maintain their continuity of care, says Dino Kasdagly, chief operating officer of L.A. Care.

"This puts the onus on the provider," Kasdagly says. "On a yearly basis, they have to attest to the accuracy of their licenses, credentials, specialties, demographics, offices, and office hours."

Specifically, SB 137 requires providers to inform health plans within five business days if the provider is no longer accepting new patients, or is accepting them again, after a period of having not done so.

All this has created business opportunity for technology providers, and in this regard, L.A. Care uses LexisNexis, which maintains a master database of data on provider demographics, Kasdagly says. This database relies upon more than 2,000 sources of data and covers more than 8.5 million providers, according to LexisNexis officials.

Data Discrepancies

"They'll come back to us with discrepancies that we have within our information," Kasdagly says. "We will then not just take it for granted. Because there are errors in all databases. We will also research the findings and either go back to Lexis with our findings, or we [find that we] agree with Lexis's findings, which is a very high percentage; they're more accurate than what we have."

Kasdagly was not able to characterize how big a problem inaccurate provider directories are for L.A. Care, but a study this year by researchers at West Virginia University found these directories to be shockingly inaccurate.

He was unwilling to share what kind of annual provider turnover L.A. Care experiences annually. "It's not zero, and it's not a very high number either," Kasdagly says. "I don't worry about those. Those we can capture."

These changes fall under the multitudes of other provider changes, such as providers that have:

  • Added phone lines
  • Joined an independent provider association or another organization
  • Changed office hours and/or locations

SB 137 has a number of other provisions. By the end of July 2017, health plans' Web sites must be able to let visitors search by name, practice address, city, zip code, California license number, national provider identifier number, admitting privileges to an identified hospital.

The main effort of the bill is focused on ambulatory and specialty care providers.

General acute care hospitals are exempt from some of the requirements of the bill which prevent them from being removed from provider directories if they do not respond to requests for information updates.

Still, the overall effect of SB 137 and legislation like it will be to improve consumer experience and perhaps make some headway on the backlog of referral requests for specialists.

"The teeth [in SB 137] will make a difference from a member perspective," Kasdagly says.

Scott Mace is the former senior technology editor for HealthLeaders Media. He is now the senior editor, custom content at H3.Group.

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