Provider data standardization critical to improving inaccuracies data recovery pc

“Inaccurate provider data has long been a significant challenge for healthcare,” said CAQH Executive Director Robin Thomashauer. “Individual providers, provider organizations, patients and health plans are all affected by this issue, and it requires a collaborative effort to achieve real change.”

Over one-half of physicians in a recent American Medical Association (AMA) and LexisNexis Risk Solutions survey said their patients faced coverage issues at least once a month because of data inaccuracies in provider directories. Patients were unable to access accurate information on practice address, contact numbers, network designations, and new patient acceptance.

A recent CMS audit of Medicare Advantage plan directories also revealed that 52 percent of practice locations listed had at least one inaccuracy, and provider directory inaccuracies with the greatest likelihood of interfering with care access were found in almost 46 percent of all locations.


Few aggregators of provider data exist that can authoritatively gather data elements and create complete provider data records, the Alliance explained. And for many data elements, no accurate sources exist for stakeholders to use, creating data compatibility challenges.

Adding to the provider data issue is the fact that payers have different provider data standards and requirements, the Alliance added. Payers use different reporting formats and the industry has not adopted a single standard transaction type or application program interface (API).

Providers also tend to be unaware, or misinformed about, how their data is used by payers. For example, providers may submit practice locations for provider directories that are accurate for medical billing purposes but not for patient access.

“Variations in the format, exchange, content and understanding of the uses of provider data represent an unnecessary cost to the healthcare system and an obstacle for patients and other users of data who need access to reliable provider information,” the group wrote. “As a result, provider data is communicated inefficiently, causing attrition during transmission and encouraging data users to source data directly rather than decipher inconsistent datasets that have been sourced by others.”

Standardizing provider data and developing the infrastructure to support the information is a monumental task, but the Alliance emphasized that the industry can achieve these goals by formally committing to provider data improvement and creating a non-profit multi-stakeholder group to lead the efforts.

This group will lead an incremental approach to establishing provider data standards, technology standards, common operating rules, data quality standards, and technological infrastructure. The group will also be responsible for ensuring distribution of and adherence to provider data standards, as well as measuring the industry’s progress with the provider data improvement.

“Through the development of this Roadmap, the Alliance and its participants agreed that the industry must chart a new path toward a more accurate and efficient provider data ecosystem,” the CAQH group concluded. “The pressing needs of stakeholders require that momentum be developed quickly, while ensuring a holistic, measured and methodical approach.”

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