Why Accurate Provider Data Is a Win-Win for Everyone

Everyone Wins with Accurate, Streamlined Provider Data

Imagine this: You have two sisters who are both sick and need urgent care. You offer to help them find a doctor and decide to search for an in-network doctor through their respective health plans. One sister has health plan A through her employer, and the other sister has health plan B, which is offered through her spouse’s plan.

Now, imagine that the best doctor in town for treating their condition has different data on the two health plan portals. In Portal A, that doctor is listed as working at a clinic location right down the road from your sister’s house, but Portal B says the doctor works several miles away. One portal states that the doctor isn’t taking new patients, while the other claims that the practice is open.

As the person relying on this provider data, you want to ensure that your loved ones receive the care they need from highly qualified providers promptly. You likely don’t care in the slightest who has aggregated the data, or who found the correct data, or even who got the data first. You just want the data to be correct.

This is the analogy that Mike Kane, SVP of Provider Data Operations at UnitedHealthcare, shared during his presentation at Certify’s Blueprint Summit. In his panel session titled “The Data Integrity Crisis,” he and Jamila Sykes, VP of Provider Data Operations and Reimbursement at Highmark Health, shared why health plans all win when provider data is accurate and up to date.

During the session, they shared an insight that caused a paradigm shift for us: Health plans aren’t in competition when it comes to provider data. They may compete when it comes to attracting and retaining members, winning employer contracts, and even reducing costs while improving outcomes, but when all health plans have access to good provider data, everyone benefits.

Mike and Jamila explored why innovative solutions, including a shift toward payer collaboration, could enhance provider data for everyone, ultimately yielding significant benefits for the entire industry.

It all starts with good provider data.

The Root Causes of Bad Data

Mike shared that at UnitedHealthcare, they look at provider data as a pool. In an ideal world, the pool water would be squeaky clean, and the faucets pouring into the pool would be well-controlled and provide good, clean data. Unfortunately, in our current data integrity crisis, the “water” in that pool is full of outdated and incorrect information.

What’s more, Mike explained that on top of a dirty pool, there are dozens of sources pouring data into that pool. One faucet may be pouring in AI-aggregated data, another may be entering data supplied by providers, and yet another may be scraping data from other sources. Mike explained that this dirty pool, being fed by uncontrolled sources, has led to a big mess for every payer in the industry.

Mike says that his big "ah-ha" moment came several years ago after he conducted an audit of his team’s data management protocols. He realized that his team was doing a good job of cleaning up their current data, as well as entering new data and ensuring accuracy, yet their data pool was still dirty.

That was when his second “ah-ha” moment came: It didn’t matter how well they cleaned up the pool if the system was unbearable to providers. When providers have to jump through administrative hoops to update their data, they will eventually give up. It doesn’t matter how clean the pool is if the faucet is pouring in sludge. These admin-heavy systems are such a burden on providers and health systems that they are slow to input new or update existing information.

The daunting nature of the entire system disincentivizes providers. For example, without a single source of truth, if a doctor relocates to a new clinic, they must log in to as many as 18 different portals and complete forms with each health plan to update their address. Furthermore, in our current system, each form follows a distinct protocol and system. Some forms require a fax, while others are digital, and some are transmitted via a spreadsheet. This creates a substantial administrative burden for both healthcare systems and providers.

Jamila also cited a lack of humility in the health plan industry as a root cause. She said that each health plan has its systems and protocols for collecting data. While they agree that high-level standardization would be beneficial, they struggle to collaborate with other competitive organizations to ensure data integrity for all.

The Tangible Implications of Bad Data

The scenario we shared at the start of this blog post about the two sisters who didn’t have accurate information is just the tip of the iceberg when it comes to the implications of insufficient data.

Health plans are accountable to their members, and when members can’t find in-network providers, it causes confusion and frustration. It can also mean that members have to attend doctors’ appointments and pay out of pocket, or that members spend hours on the phone trying to access care.

Data integrity also causes provider frustration. Administrative teams must navigate complex processes to assist members in obtaining appointments and services that are covered by insurance. Providers want to be paid quickly and accurately for their services, and when their data is incorrect, their payments could be delayed or reduced.

A third significant implication concerns healthcare regulators. Health plans are required by law to provide high-quality care and access to services. When secret shoppers get inaccurate provider data from a health plan, it can result in regulatory impacts and even fines.

Collaboration as a Win-Win

Data integrity is one area where health plans have no competitive advantage over others. If there were one pool – a single source of truth – and one faucet full of clean data pouring into that pool, then every single health plan, member, and provider would win.

This is our mission at Certify.

We know that payers and providers alike want a cleaner pool of data. It’s what both Mike and Jamila have been working on for years, and while they have made significant strides in cleaning up their data and implementing systems that control those faucets, they both recognize that there's still work to be done.

This starts with a shift toward collaboration. Every payer should share data and ensure that the pool of information is both accurate and up-to-date. From there, they need to collaborate to create a system that simplifies maintenance and administration. Certify is leading this shift. By working to bring payers, health systems, and providers together in hopes of a future where every member can find every bit of information they need so that they can get help fast from the right provider, in the right place, and at the right time.

Certify has built the infrastructure to meet that need. We are the single source of truth for provider data, and our vertically integrated, centralized platform can serve as that squeaky-clean pool. Now it’s time to open up the faucets. Accurate, accessible provider data can benefit every provider, member, and payer; however, we must all align if we want to achieve system-wide transformation.

It starts with collaboration, and Certify is ready to be the connective piece that ensures that the data pool is clean and prepared for the future of healthcare.

We are Building What Healthcare Runs On

Certify’s Provider Data Management platform is the only end-to-end solution with a unified, real-time, 360-degree view of every provider in your network. And as a data-first company, we are a flexible partner that’s able to meet you where you are today while building for the future. This isn’t a point solution. It’s new infrastructure.

Ready to explore how our PDM solution can help you manage the future of your provider data need? Book a demo with one of our experts today.