LexisNexis Identifies Top Gaps, Challenges in Health Care Provider Data Impacting Compliance with CMS Directory Requirements

For Health Insurers, MCOs, Bad Provider Data Can Cost Millions

Feb 03, 2016, 10:00 ET from LexisNexis Risk Solutions

ATLANTA, Feb. 3, 2016 /PRNewswire/ -- LexisNexis® Risk Solutions announced today that it is assisting the health care market address recent federal and state regulatory requirements tied to provider directory accuracy through its LexisNexis® Provider Data Intelligence Suite. Inaccurate or missing provider data negatively impacts compliance, member and provider relations, as well as other critical work streams. LexisNexis health care internal analysis has found that when factoring in administrative activities to correct the errors, customer satisfaction, return mail, fines, penalties or other sanctions, such as directory requirements from the Centers for Medicare and Medicaid Services and state agencies, bad provider data costs the U.S. $23-26 billion per year. 

New, tougher mandates, such as the Federal Exchange, Medicare Advantage and Qualified Health Plan Directory Data Requirements enacted in 2015, pushes health care organizations to maintain accurate provider information.i Stipulations for compliance include giving providers a means by which they can self-attest their information by plan in which they participate. Penalties for non-compliance can be severe. In the case of Medicare Advantage directories, the penalties stipulate inaccuracies may trigger penalties of up to $25,000 per day per beneficiary or bans on new enrollment and marketing.ii

LexisNexis is shifting how the market approaches provider data quality and maintenance by providing a systematic method for plans to proactively address the demand for accurate provider data information with its Provider Data Intelligence Suite. The suite provides a continuum of data assets, real-time validation, agile data management and technology-enabled phone validation, as well as a portal through which providers can attest their information. This robust offering helps alleviate the administrative burden for plans allowing them to focus on caring for their members.

Leveraging the industry's most in-depth provider data with more than 100 million provider transactional verification touch points per month and the only payer and retail pharmacy contributory model to reduce latency and offer a direct feedback loop, LexisNexis health care provider data assets include:

  • More than 8 million Health Care Practitioners (HCP)
  • New automated technology portal and phone and email validation services
  • More than one million unique facility, group and other business entities and Health Care Organizations (HCO)
  • Complete affiliations between HCPs and HCOs and Integrated Delivery Network, Group Purchasing Organization and Accountable Care Organization affiliations and healthcare networks
  • Current provider credentials and expanded demographics with verification detail

"To succeed in this complex environment with constantly changing information, health care organizations need more than access to quality and comprehensive data; they need a technology solution partner that can help them be proactive and thorough in their strategy," said Lee Rivas, CEO, Public Sector and Health Care, LexisNexis Risk Solutions. "Working as a partner with federal and state regulatory bodies quickly is one piece of the puzzle; understanding the overall value of a proactive data management strategy is what results in millions of dollars in savings."

The LexisNexis Provider Data Intelligence Suite helps payers cleanse their directories, eliminate inactive addresses, correct contact information, create automated updates, gives providers a portal through which they can verify and validate their information and ensures accuracy for better patient experiences. LexisNexis also has the ability to link its public records data, providers and their affiliations through its advanced and high-performing big data processing technology platform, HPCC Systems. LexisNexis analytics capabilities and technology are used to dynamically track provider changes, provide data in real-time for patient interactions and ensure actionable results for health care organizations.

"Nearly every decision that is made within a payer, by a member or by a stakeholder (like provider), can potentially benefit from the analytic insight made possible by big data," said Jeff Cribbs, Research Director, Gartner. "Among the benefits that payer CIOs can expect from big data are improved engagement with customers, more meaningful care management, more sophisticated management of provider networks and contracting, faster detection of potential fraud and abuse, more effective marketing, and optimized sales channel performance."iii

About LexisNexis Risk Solutions
LexisNexis Risk Solutions (http://www.lexisnexis.com/risk/) is a leader in providing essential information that helps customers across industries and government predict, assess and manage risk. Combining cutting-edge technology, unique data and advanced analytics, LexisNexis Risk Solutions provides products and services that address evolving client needs in the risk sector while upholding the highest standards of security and privacy. LexisNexis Risk Solutions is part of RELX Group plc, a world-leading provider of information solutions for professional customers across industries. 

i Published on February 20, 2015, 42 CFR Section 422.111(b)(3)(i); 422.112 (a)(1) states that Medicare Advantage plans, Qualified Health Plans (QHP) and Stand-Alone Dental Plans (SADP) offered through the Federal exchange need to have up-to-date and accurate provider directories in order to demonstrate provider network adequacy. 
ii Provider Directories: Litigation, Regulatory, and Operational Challenges, BRG Healthcare, March 2015 
iii Gartner, Hype Cycle for U.S. Healthcare Payers, 2015, Robert H. Booz,|  Jeff Cribbs,  Constance Sjoquist,  1 July 2015

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