Large Regional Payer: Eliminating Ghost Providers

Ghost providers: they’re the healthcare industry’s worst-kept secret, lurking in the shadows of provider directories and leaving patients and professionals grappling with the specter of care that’s simply not there.

Industry: Health Insurance

Size: Over 1 million members

Plans Offered: HMO, PPO, POS, Medicare and Medicaid

Goal: To promote community health and well-being by ensuring comprehensive coverage and accurate provider information.

The Challenge

Our client faced a significant obstacle with their provider data integrity. The attestation results from its attestation vendor were not meeting the desired standards, with a coverage and accuracy rate lingering around 40%. This data integrity issue posed a risk to the reliability of their healthcare network, member satisfaction, and regulators.

The Solution

In a decisive move to rectify these shortcomings, the payer partnered with Convergent. The mission was to auto-cleanse and enrich the provider data that was not covered through the standard attestation process. Convergent’s technology and call center was leveraged to sift through data, verify provider details, and update records with accurate, active locations. For those providers that needed additional verification and enrichment, the call center used Convergent to prioritize the highest risk providers for outreach.

The Results

The collaboration with Convergent bore significant fruit:

• Improved Data Integrity: Correct provider locations were identified, particularly for those previously marked as inactive.
• Enhanced Network Accuracy: The accuracy of the network data saw an impressive improvement of over 30%.
• Seamless Data Integration: The auto-cleansed data was integrated flawlessly, ensuring that the updated information was immediately reflected across the client’s system for member access.

Conclusion

Through this partnership, our client significantly enhanced the reliability of its healthcare network, benefiting over a million members. The case exemplifies how embracing innovative data solutions can overcome complex challenges and drive better health outcomes in the community.

Learn how to improve your member experience with automated provider data management.