Provider Data Management

A Real Solution

Author's Corner

In his white paper, Mark Kausel, Director of Client Services a real solution to provider data management.

Please click on the video to the right to learn more about the author, his paper’s key takeaways, and his motivation for writing on this subject.

To discuss this white paper at length, please contact Mark using the information provided at the bottom of the white paper.

The Challenge Around Provider Data

Throughout the healthcare industry, there is a vital need for accurate data about providers, yet organizations struggle to acquire and maintain the information they need to perform the most fundamental processes. Complete, accurate and timely data is needed to publish provider directories, make appropriate referrals, credential providers, submit and adjudicate claims, manage affiliations and networks, and more. Inaccurate data about providers can lead to financial penalties, delayed reimbursements, denied claims, lost revenue, and dissatisfied customers. It is estimated that healthcare organizations (hospitals, physicians, health plans, etc.) spend over $2 billion annually to maintain the integrity of their provider data.

Provider data is constantly changing, making it extremely difficult to manage. According to a 2016 IDC Health Insights report, “2 percent of provider demographics change each month, an estimated 20 to 30 percent of physicians change affiliations each year, while 5 percent of doctors change their “status” – lose licenses, die, retire or are sanctioned annually.”i

In addition to the constant change, other contributing factors include limited “authoritative” data sources, the wide variation of requirements, a lack of standardization, and an absence of provider engagement. Each organization independently manages these challenges, often without the capital budget to make substantiative change, creating even more inefficiency and waste.

Improving the Provider Data Management Process For Better Patient Outcomes

More than half of 703 physicians surveyed in 2018 found that their patients encounter coverage issues due to inaccurate information included in payer directories at least once per month, according to the American Medical Association (AMA) and LexisNexis Risk Solutions.ii

For patients this creates challenges finding a qualified in-network provider to perform the best care at the lowest cost, helping them avoid surprise bills. The lack of a comprehensive payer directory leads to poorer outcomes for patients and frustrations and dissatisfaction when the bills arrive.”

What is Provider Data Management?

Provider Data Management (PDM) utilizes technology, services, and procedures to enable healthcare organizations to effectively collect, aggregate, and manage comprehensive information about the providers who supply services in their ecosystems. This data is used for many purposes and begins as providers join the healthcare organization through the credentialing process. This procedure is used to verify that providers are qualified to provide care for patients. Credentialing is an ongoing process since certain qualifications need to be renewed periodically.

Table 1 references the types of information required in the credentialing process. The data required to support this process comes from the provider and other independent sources. If credentialing or recredentialing data is not accurate, healthcare organizations may allow unqualified providers to care for their patients which creates a significant risk for the patient and provider organization. CMS now issues fines for inaccurate network directory data, which can also lead to dissatisfied patients. Incorrect data on claims can lead to additional claims processing work, and/or denials, resulting in lost revenue.

Provider Data Management

Provider information will be used to publish network directories to make it easier for patients to find providers who are best able to provide the care they need. Usually this includes a provider’s specialty, office locations, office hours, telephone numbers, accepted insurance plans, and whether they are accepting new patients. Much of this information comes from the provider or their administrative staff.

Finally, to be reimbursed for the services they deliver, providers must supply accurate information so that claims can be processed and payments received. In many instances, this will include service locations, National Provider Identifiers (NPI), banking information, and copies of the provider’s W9. This data is usually given by the provider or their administrative staff.

Provider Data Management is challenging because some data are static, not changing, while other data are dynamic and may only occasionally change. Additionally, there is no single authoritative source for this information, making it very complex to manage. In many cases, it is the provider who is responsible for supplying the data and their priorities tend to focus on patient care rather than administrative tasks. The result can be inaccurate data about the provider, which can lead to costly consequences.

A good provider data management solution will mitigate the risks to patients and minimize the financial impact to an organization.

The Best Provider Data Management Solution

The Provider Data Action Alliance, which was convened by CAQH in March 2017, published an industry roadmap for provider data. It included core principles, a vision, and a roadmap to achieve the vision . The vision of the group was to create a not-for-profit organization comprised of industry stakeholders (including providers to govern), define a set of key provider data elements, and create a centralized authoritative solution that would grow in scope over time.

The core principles state:

  • The time and attention of providers must not be wasted
  • The solution must be flexible and adaptable
  • The solution must be pragmatic and focused on near-term business realities
  • The solution should be industry-governed and standards-based

Providers have a vested interest in ensuring the data about them is accurate and maintained in a timely fashion. To date, this vision has not been fulfilled; however, there are several commercially available solutions.

Organizations can achieve the tenants set forth by the PDAA, mitigate risks, and best leverage their time, talent, and energy by:

1) Implementing a robust technology platform

The centralized platform will accurately and efficiently collect, consolidate, and share provider data across the enterprise. This will ensure standards for data governance and stewardship are applied uniformly. It will leverage predictive analytics, machine learning, and other data-driven applications to help users make more informed decisions.

2) Leveraging best practices in the adoption, deployment, and sustainment of a PDM solution

Start small and grow, aligning investments with business value as deployed. It is important to define, measure, and monitor throughout the process. How is the quality of the data from the end-user’s perspective? Is it easy to access? Are providers engaged in timely updates of their data?

3) Engaging the best people

Involving people with the right skill sets will build a strong team that is able to collaborate, contribute and deliver the desired outcomes. Governance needs to include executive leadership, key stakeholders, and most importantly, have provider representation and buy-in.

A proactive, strategic stewardship of provider data, supported by the right mix of people, processes, and technology will result in more accurate provider data and improved network provider directories, support more accurate claim payments, reduce the cost to process claims, decrease compliance issues, improve patient and provider satisfaction, and provide a solid foundation for provider engagement and better patient outcomes.

Vee Healthtek’ success with provider data management is rooted in our highly competent people, knowledge of best practices and leveraging technology in a comprehensive solution to achieve our clients’ goals. Whether it is credentialing, provider data management, or other provider data related needs, Vee Healthtek will bring the Technology, Accuracy, Competency, and Teamwork to deliver an extraordinary provider data management outcome.


Mark Kausel

Meet the Author

Mark Kausel - Director of Client Services

Mark Kausel applies over 30 years of experience from healthcare operations, information technology, and sales and account management roles to deliver strategic solutions to client challenges, resulting in positive outcomes with long-term relationships.