Wed, 11/07/2018

While many healthcare systems have implemented Enterprise Master Patient Indexes (EMPIs) for patients, few have embarked upon the daunting challenge of mastering providers. But there is a growing list of reasons why mastering providers is of equal financial importance. Healthcare organizations implement EMPIs to maintain up-to-date and accurate information about every patient. And for good reason: Inaccurate patient identification or information results in 33% claims denial and costs the US healthcare system over $6 billion annually.


Unfortunately, mastering a provider is so much more difficult then a mastering a patient. There are many reasons why.  A provider is not just a doctor, that term can extend to nurse practitioners, physician assistants, and more.  Layer in the dimension of a provider being employed, affiliated, and/or independent and the challenge is further exacerbated.  A sophisticated system will be able to facilitate a provider that is not currently in your system yet is a valid provider.  EMRs struggle with the existence of someone that does not exist in their system.  With their inability to incorporate HR data, a provider does not exist until they are seen by a patient in a setting in which the EMR vendor is in place. 


Organizations have to update physician data because of the dynamic relationships among physicians, group practices, hospitals and payers, and universities. The typical hospital maintains physician data for each department. Partial physician lists get duplicated, with varying data elements and no synchronization or validation. The typical organization will have at least twenty unsynchronized physician lists in various departments including marketing, physician recruitment, medical records, claims processing, emergency department, and hospital services.


Harmonized provider data is a must, particularly when the physician files claims under multiple National Provider Identifiers (NPIs) – their own, their practice’s, and their hospital’s. Inaccurate information can introduce delays in claims reimbursement, create frustration on the part of the patient, and make it difficult to perform provider benchmarking.


Tracking physicians through these variances can be daunting:


  1. In group-level reporting, when practices have poorly-aligned physicians, this impacts the quality of care provided, and skews benchmarking costs. Additionally, proper physician attribution for value-based and clinical quality outcome metrics is essential to building trust with caregivers for any type of performance improvement activity.
  1. In shared savings programs, when mis-aligning physicians with practices could result in savings attributed inaccurately to the wrong practice. Inaccuracies or mismatches between the practice and payer data result in delayed reimbursements.
  1. In insurance plans, if information is inaccurate, members will become frustrated when attempting to find a provider for their care needs. Worse yet, they could schedule an appointment based on the information on the plan’s website, only to find that the provider is out of network or does not practice the correct specialty. If the payer needs to communicate with the provider, but does not have the correct contact information, there may be a delay in claim payments.


The Center for Medicare and Medicaid Services (CMS) imposes fines for inaccuracy and non-compliance in the provider directory. Incorrect information can lead to problems with value-based payments for alternative payment models. Compounding these challenges is temporality, which is critical for proper coding and tracking, as well as for recreating the patient journey from a point in time in the past.


Given the fluidity of a provider in various settings, it is important to “master” subjects such as the provider, the practice, and the location or facility, to give the highest level of confidence that the golden record will be accurate. Temporality is foundational to the mastering process, creating the ability to go back in time and see exactly where the physician was and in what setting relevant to a claim or a patient encounter.


Physician mastering can’t be done properly without addressing data quality problems along the way. It’s a case of “garbage in, garbage out:” If physician data is erroneous in one or more systems, there is a high likelihood that any future interaction with the data will cause inaccuracies.


Market changes, such as value-based purchasing and alternative payment models, have created the need for greater clinical integration across the continuum of care. Trusted, timely, and accurate data is essential to the delivery of value-based care.


But there are mountains of data spread across a host of systems that provide only a partial record of the patient journey. Those systems need to be aggregated and collated to provide a holistic view of the patient, yet they were never designed to be integrated into a broader view.


By providing an enriched repository of data, an organization can begin to integrate clinical and business domains, improve care management, analyze where cost reductions are possible, evaluate market share growth opportunities, provide performance benchmarking for improvement in care quality, and most importantly, positively impact the overall patient/member/consumer experience.


Find out more about how we can help you with your provider mastering projects, by contacting us on our website or calling 800-969-INFO.