Provider Directories and Drug Formulary
Reconciling the Accuracy of Provider Directories and Drug Formularies doesn’t have to be Arduous
Compliance sets a high bar with penalties and fines when it’s NOT 100% correct.
Recent CMS regulations require provider directories be accurate and updated on a monthly basis. This information not only includes that the provider was in network, but that their demographics, locations and which providers are accepting new patients.
Errors in this information can require out-of-network claims to be paid as in network, and can also open up the health plan to government fines and sanctions as well as lawsuits. Some states also allow members a Special Enrollment Period (SEP) if the provider directory information used to select their plan was found to be inaccurate.
In addition, prescription drug formularies for marketplace plans are also required to be 100% accurate, or the health plan risks accruing fines.
Semi-automated and manual processes to ensure 100% accuracy is costly and fraught with errors Automating and tracking data Integrity non-intrusively across complex processes are core capabilities of the Infogix Enterprise Data Analysis Platform. This ensures that data is reconciled across multiple sources and destinations so that the information is correct in printed and online directories, as well as the CMS machine readable format. Through automated data analysis from source to destination you have a complete audit trail of any data anomalies and are promptly alerted with exceptions to resolve immediately before bad data propagates into published provider directories and/or drug formularies.
By reconciling data with configurable business rules you ensure that data is 100% accurate and avoid the embarrassment and compliance fines of publishing inaccurate data.