providerdirectory

We've talked extensively about the problem with provider directories. It's a fundamental issue in healthcare administration and many of our processes are built on top of it. I've called it healthcare's ultimate death by paper cut. Now, we're starting to see new solutions in the market. Last week we looked at an open-source industry solution. This week we're looking at the statewide effort in California.

California's Senate Bill 137 (SB-137), the "toothiest" provider directory law to date, set the stage for a state-wide collaboration that would have been otherwise difficult to attain. Today I'm joined by Jon McBride, CTO at Integrated Healthcare Associates and Rajan Shah, VP of Business Development at Gaine Healthcare to learn more about California's Provider Directory Utility and find out what happens when you get the entire healthcare industry rowing in the same direction to solve a well defined problem.

 

3:25 The Integrated Healthcare Association convenes diverse stakeholders to solve industry-wide inefficiencies in a non-competitive environment to find common ground solutions. 

4:45 What is the California Provider Directory Utility (PDU) and how does it affect me?

7:13 How does Gaine Healthcare's data management solutions work with Availity and Integrated Healthcare Association (IHA)?

9:13 The plumbing of the data points, finding relevant data sources, and going to where the data already is.

11:44 Big launch or small pilots? How does IHA plan to take on such a big project?

14:35 How tough are the regulatory hurdles? Is California working with you or against you?

17:12 What are the key metrics to demonstrate that you’re making progress?

19:10 Were there any difficult or surprising issues in bringing stakeholders together? What was your approach to solving a common problem without doing the same old thing that got us here in the first place?

22:15 Now that regulators are serious about enforcing this law, everyone is rowing the same direction. This is collaboration like we've never had before. We're building an industry utility that everyone will benefit from.

25:35 The money set aside to be used for this project was from the merger of Blue Shield and Care First. What’s the plan to keep it funded as a utility in the long run?

27:55 An overview of the solution. What is the PDU? Architecture, components and points of interaction.

31:50 The integration model. Are you really going to go to every provider in the state 1-by-1? Do you have the staff for such a large operation?

34:00 How do you deal with over 300 large provider organizations, more than 50 different managed care plans and thousands of mom and pop practice with widely different EHRs and not a lot of technical support?

36:30 What are you doing that helps you manage mass integration with smaller staff? How do you scale high touch? The tech platform plays critical role. We do all the integration. Health plans and providers don't have to change their process and won't need additional staff.

43:01 The power of effective regulation.

44:41 Soft launch. What is it? The 3 phases are data integration, day to day operations, and attestation.

51:00 This was the right time to get the problem solved. We have 40M people waiting on us and the benefits of fixing this problem will be huge!

 

The PDU is in soft launch through the end of 2018 and will be available to providers and health plans across California in early 2019.

Sign up here to receive updates about our progress and launch.

Check out this CMA webinar about the PDU

 

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About Jon McBride, MBA, Chief Technology Officer at Integrated Healthcare Association (IHA) 

Mr. McBride is a business-focused technology executive who has spent the last 25+ years working in technology endeavors, startups and innovative healthcare teams.  Mr. McBride currently leads and builds mission critical systems as IHA's PDU CTO and as founder/CTO of Sunfish Health.

Mr. McBride previously founded Sunfish Health and Afoundria - and currently serves on both Boards; and served as startup CTO and CIO of Availity, building a technology platform that, at the time, grew to over 2 billion annual healthcare transactions and averaged more than US$1 billion per day in electronic healthcare claim submissions. Previously technology executive and software developer at several companies and ventures, including Lockheed/NASA, St. Jude Children's Research Hospital and Johns Hopkins.

Jon McBride on Twitter

 

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Rajan Shah, VP of Business Development at Gaine Healthcare

Mr. Shah currently serves as the Vice President of business development at Gaine Healthcare. His primary focus is centered around healthcare organizations, both payer and provider alike, looking to expand upon master data principles and healthcare interoperability. In the past, Mr. Shah has served as an Information Technology Director over clinical applications and innovation within a payer/provider delivery system focusing on electronic medical record solutions as well as health information exchanges. As a part of that, he focused heavily on analytic solutions that helped manage the health plan's population base.

Raj Shah on Twitter

http://www.gainesolutions.com/hc

 

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About Integrated Healthcare Association

Integrated Healthcare Association (IHA) is a nonprofit organization that convenes diverse stakeholders, including physician organizations, hospitals and health systems, health plans, purchasers and consumers committed to high-value integrated care that improves quality and affordability for patients across California and the nation.

With the support of industry leaders across California, IHA is leading the development and roll-out of a statewide Provider Directory Utility (PDU) to simplify the provider data management process, reduce administrative work, and make it easier for healthcare providers and health plans to meet requirements.

The California Provider Directory Utility Website

IHA website

IHA Twitter

IHA Linkedin

Upcoming events with IHA

 

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Related and/or Mentioned on the Show

 

How to Tap Existing Processes for Provider Data | Martin Dunn | Gaine Healthcare

A Provider-side Approach to Provider Directories plus SB-137 | Bill Barcellona (CAPG)

Provider Data: What is Known and What is Assumed? | Mark Martin | Availity

See all of The #HCBiz Show's extensive coverage of the Provider Directory problem

 

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The #HCBiz Show! is produced by Glide Health IT, LLC in partnership with Netspective Media.

Music by StudioEtar

Healthcare is the most intermediated business in the history of the world. There's always someone, and usually several someones, in between the clinician and the patient. Similarly, while most of us working on the business of healthcare will enthusiastically agree that we do this for the patients, we spend very little time talking about them. Of course, I'm not referring to the "front-lines" of healthcare delivery (i.e. doctors, nurses, etc.) or even their immediate support team at the hospitals and clinics. I'm talking about those of us who are working in the background to enable "healthcare transformation".  While we try to fix provider directories, calculate quality measures and otherwise streamline the business of healthcare, we're regularly focused on the complex, technical details of those problems. The concept of the patient is usually abstracted. Even when we talk about things like "covered lives", we tend not to discuss them as actual people; as our grandparents or brothers or children.

That's not wrong, per se. We all need to focus on our part of the mission and trust that our "team" is giving us the right problems to solve. However, we may be selling ourselves short. It can be incredibly powerful to remind ourselves from time to time that we are, in fact, ultimately working for the patients. It's the "commander's intent" behind what we're doing and should guide us as we make 100s of seemingly unrelated micro-decisions throughout our day. The expanded perspective helps us to re-center our "why" and keeps us moving productively towards a healthcare system that works for all of us (i.e. patients, providers, health plans, administrators, entrepreneurs, government, etc.).

That's why we talked to Tam Ma, Legal and Policy Director at Health Access California. Tam explains why provider directory accuracy is so important from the patient's perspective and why her organization was vocal in the crafting of California's SB-137 legislation. In doing so, she helped me realize that we're aiming way too low with our solutions in this space. We're still struggling with the basics:

• Where does the doctor work?
• How do I contact them?
• Are they accepting new patients?
• Will they accept my plan, or will I get nailed with dramatically higher out-of-network charges?
• Etc.

We've demonstrated the reasons why these seemingly simple questions are so difficult to answer throughout this series. It's hard, but we shouldn't expect any pats on the back when we're done. Instead, we should expect a resounding "It's about time" from the patients. That's because we're still playing catch-up with their most basic expectations. I should know who's in a plan before I buy it. They should be able to tell me the doctor's correct phone number. By looking at this patient perspective, we can start to see why this isn't enough. It's a step on the path, but we need to aim higher so we can start to deliver real value and truly address the convenience and access issues that patients face. When a patient can reliably search for a dermatologist who participates in Medicaid, is accepting new patients, offers Saturday appointments and has an office (that they actually work at) on the 15 bus line, then we'll have arrived.

Tam and I break down these ideas and much more including:

• What is Health Access California?
• Why did you get involved in SB-137?
• Where do provider directories fall short?
• Who's responsible for provider directory accuracy? Who should be held accountable?
•  SB-137 has provisions that allow health plans to take action against non-compliant providers (i.e. de-listing). Are these viable options in the face of network adequacy regulations and other tangential pressures?
• Beyond having accurate information, how can we improve provider directories for the patients?
• What customer-facing tools can we adopt from other industries like retail?

Bonus: Tam tells us about new regulations in California that protect patients against unexpected out-of-network bills.

I hope this episode broadens your horizons on what a proper provider directory should look like. It did for me.

Enjoy!

- Don Lee

Check it out on:

 

http://bit.ly/HCBiz-iTunes 
http://bit.ly/HCBiz-GooglePlay 
http://bit.ly/HCBiz-Stitcher 

Prefer to read it? Grab the full transcription PDF here!

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About Tam Ma

Tam M. Ma is Legal and Policy Director at Health Access California, where she represents the interests of health care consumers in the Legislature and before administrative and regulatory entities. Tam started her career as a California Senate Fellow and was previously senior staff to Senators Mark Leno and Sheila Kuehl, where she advised the Senators on policy and state budget issues relating to health and human services, consumer protection, housing, judiciary, and women's issues. She also advocated for the rights of low-income tenants when she was a trial attorney with Legal Services of Northern California's Sargent Shriver Civil Counsel Act project.

Tam was honored by the California Partnership to End Domestic Violence and the California Coalition Against Sexual Assault for her work to strengthen protections for survivors of these crimes. She sits on the board of the Women's Foundation of California and has served as a trainer and mentor for the foundation's award-winning Women's Policy Institute since its inception in 2003. Tam also serves on the board of the Asian/Pacific Bar Association of Sacramento and is Past President of My Sister's House, a domestic violence shelter serving women throughout the Central Valley. Tam received her B.A. and J.D. from the University of California, Berkeley.

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About Health Access California

Health Access California is the statewide health care consumer advocacy coalition, advocating for quality, affordable health care for all Californians.

As a coalition organization representing consumer groups, communities of color, immigrants, people with disabilities, children, seniors, women, people of faith, and organized labor. Health Access seeks to connect grassroots organizing to policy work, on-the-ground mobilization with savvy Sacramento strategy. Coalition member organizations can count on Health Access for timely analysis and tools so that whatever time and effort they have for health advocacy is spent in the most effective way possible.

http://www.health-access.org/

@healthaccess

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Mentioned on the Show

Secret Shoppers Find Access To Providers And Network Accuracy Lacking For Those In Marketplace And Commercial Plans (Health Affairs)

DMHC Fines Blue Shield and Anthem for Provider Directory Inaccuracies

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About the Provider Directory Podcast Series

This episode is part of our ongoing Provider Directory series that aims to dissect the issue from all perspectives, including provider, payer, patient, and regulator. Our goal is to help facilitate an expanded national conversation that drives us towards an open, collaborative industry solution.

Check out all our Provider Directory posts and episodes here!

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Weekly Updates

If you like what we're doing here, then please consider signing up for our weekly newsletter.

---

The #HCBiz Show! is produced by Glide Health IT, LLC in partnership with Netspective Media.

Music by StudioEtar

How do you eat an elephant? One bite at a time.

That may be the best advice I can give the healthcare industry at this point.

On this episode, we talk with Dave Marotz, Director of Directory Services at Surescripts to break down the Provider Directory concept into its component parts... "capability style".

We go deep on the technical and architectural hurdles that need to be overcome to progress Provider Directory. You'll learn about:

1. The various standards-based approaches that have been/are being attempted.
2. New wrinkles on provider context and how we may need to know what the truth was about them at a certain point in time (i.e. rights to dispense a prescription).
3. What should be shared? Who should own the "shared data"?
4. Why it's hard to get something as simple as proper provider names.
5. Strategies for identity proofing and identity resolution.
6. Decomposing the conceptual master provider directory into its component parts
7. The various industry and commercial approaches to provider directory solutions.
8. The wisdom of working prototypes over ideas for standards or approaches.
9. How Surescripts evolved, why they're so interested in Provider Directory and why they're so supportive of collaborative solutions.

Dave is a technical wizard when it comes to provider directory data and networks. Get ready for a mental workout!

~Don Lee

Check it out on:

 

http://bit.ly/HCBiz-iTunes 
http://bit.ly/HCBiz-GooglePlay 
http://bit.ly/HCBiz-Stitcher 

Prefer to read it? I don't believe you, but I'll still let you download the PDF here!

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About Dave Marotz

Dave Marotz is Director of Product Innovation at Surescripts, responsible for provider directory services which enable e-prescribing and the electronic exchange of clinical information. He joined Surescripts in 2010 to lead the network expansion for E-Prescribing of Controlled Substances (EPCS) and supported EHR and Pharmacy during development and adoption of the technology (e.g., DEA IFR Part 1311 compliance, and Identity Proofing/Two Factor Authentication requirements). Prior to joining Surescripts Dave spent seven years with Accenture’s Health and Life Sciences group leading delivery projects under FDA and CE regulations and involving cross-industry information exchange utilizing Health Level 7 v2 messaging and v3 modeling. Dave earned his undergraduate degree in Economics from St. Olaf College. In 2015, he received his MBA from Yale School of Management, focused on Leadership in Healthcare.

Contact: Dave.Marotz@surescripts.com 

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About Surescripts

Surescripts purpose is to serve the nation with the single most trusted and capable health information network. Since 2001, Surescripts has led the movement to turn health data into actionable intelligence to increase patient safety, lower costs, and ensure quality care. Visit us at Surescripts.com and follow us at twitter.com/Surescripts.

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About the Provider Directory Podcast Series

This episode is part of our ongoing Provider Directory series that aims to dissect the issue from all perspectives, including provider, payer, patient, and regulator. Our goal is to help facilitate an expanded national conversation that drives us towards an open, collaborative industry solution.

Check out all our Provider Directory posts and episodes here!

---

Weekly Updates

If you like what we're doing here, then please consider signing up for our weekly newsletter.

---

The #HCBiz Show! is produced by Glide Health IT, LLC in partnership with Netspective Media.

Music by StudioEtar

This week's guest is Martin Dunn, CEO of Gaine Healthcare. Martin frames up the current state of provider data and directory issues quite well with this quote:

"It doesn't matter how much you regulate the docs, It doesn't matter how much you've threatened the docs. It doesn't matter how much you incent the docs to pull this information together for you. If you ask questions that are difficult to answer, difficult to understand, impossible to keep up with because the doctors and the physicians and the provider organizations just don't have the systems in order to give you that information, you're not going to get it."

Sticks Won't Fix Provider Data

So, we can't just beat the doctors into submission (pun intended)? What about SB-137? That law has "teeth" to hold the providers accountable.  Not so fast, says Dunn. The first provision is that payers can withhold payments for providers who don't respond in a timely manner with quality data (Bill Barcellona called this "the Hammer Provision" in episode PD-02). That's nice, but it's probably not a good way to do business nor to build collaborative relationships between providers and health plans. The other provision is that health plans can delist providers with out-of-date data. But, as Dunn points out, then you've got health plans breaking their own network adequacy. It's kind of like cutting off your nose to spite your face.

Using Operationally Validated Provider Data

Our position at The #HCBiz Show! has always been that this provider data exists, but it's all over the place and hard to find. More importantly, you have to find it and capture it without adding new work to the providers' plate. Anyone selling into healthcare knows new work is a non-starter.

So, what can we do? Martin offers us a bit of genius on the matter: "Use the existing, trusted relationships".  He points out that the providers have already self-selected the people they trust to keep track of their most important data.  They've outsourced their credentialing to one vendor, their billing to another, and so on. Once you've identified the provider data you need, grab the provider's list of vendors and find out who's the source of truth for each element. The process dictates where the information is stored. According to Martin, we should:

"Connect into existing business processes; existing trusted relationships. Get back to their system so that we can gather that new information. When we find a conflict we can report it out to the people, who in their normal course of business, would want to resolve that conflict. We didn't find the conflict and add it to someone else's "to-do list". We've used the network to identify things that these organizations want to do anyway."

I like to refer to this as "Operationally Verified Provider Data".  If you can identify a source, where the data absolutely, positively has to be correct in order for them to do their work, then you've found your source of truth. Will it always work? No. Of course not, but you're playing the odds that the billing vendor has the most operational opportunity to find and fix problems with... billing data. That sounds like a good bet to me.

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On this episode...

I discuss these key topics in more detail and so much more with Martin Dunn, CEO of Gaine Healthcare, including:

1. Why data quality should be defined as fitness for purpose (and therefore the importance of understanding your purpose).
2. Why you should only trust the contract signatory to interpret the facts.
3. How to use a practices vendor list to build a strategy for provider data collection.
4. The challenge of tracking and balancing provider Full Time Equivalency (FTE) in support of provider directories and network accuracy (a new wrinkle that hadn't yet been discussed in our series).
5. What the future holds for the healthcare industry as it pertains to provider directory and the many efforts and collaborations that are underway to address it.
6. How Gaine Health uses its Sanator product to address these issues. Martin walks us through a few scenarios and use-cases.

This episode turns out to be a key part of our series. I promise you'll learn something new.

Enjoy!

~Don Lee

Check it out on:

http://bit.ly/HCBiz-iTunes 
http://bit.ly/HCBiz-GooglePlay
http://bit.ly/HCBiz-Stitcher

Prefer to read it? It's really long, but here you go!

Download the full transcription as a PDF.

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About Martin Dunn

Mr. Martin Dunn is an expert in the field of data management. He has founded several successful companies, on three continents focused on making information actionable for large corporations.

Martin was the co-founder and CEO of Gaine Solutions, the first company to offer Master Data Management Software as a Service (SaaS) with clients across multiple industries. Martin is presently the CEO of Gaine Healthcare which is focused on addressing the critical unmet needs of healthcare delivery organizations.

Previously, Martin was the co-founder and CEO of Delos Technology, the world’s first Enterprise MDM Software provider. Delos merged with Siperian in 2003 before selling to Informatica in what remains, the largest ever acquisition by Informatica.

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About Gaine Healthcare

Gaine Healthcare enables interoperability between disparate systems allowing clinical, administrative and analytic systems to exchange information relating to patients, health plan members, health care providers and facilities without the need for complex integration code.

For more information go to www.gainehealthcare.com/about

Gaine created the Sanator Provider Registry, a collaborative platform that enables provider organizations and health plans to exchange provider information in an efficient process that reduces administrative overhead for both parties. Sanator eliminates unnecessary outreach by phone and fax to medical offices and gives providers a trusted platform to collect and distribute information to health plans.

For more information go to www.provider-registry.com

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About the Provider Directory Podcast Series

This episode is part of our ongoing Provider Directory series that aims to dissect the issue from all perspectives, including provider, payer, patient, and regulator. Our goal is to help facilitate an expanded national conversation that drives us towards an open, collaborative industry solution.

Check out all our Provider Directory posts and episodes here!

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Weekly Updates

If you like what we're doing here, then please consider signing up for our weekly newsletter.

---

The #HCBiz Show! is produced by Glide Health IT, LLC in partnership with Netspective Media.

Music by StudioEtar

Friedrich Nietzsche argued that there are no facts, only interpretations.  It seems that this idea holds true for provider data too. Today's guest is Andrew Kobylinski, Head of Platform at BetterDoctor. Andrew tells us that the provider directory issue is first and foremost a data quality issue.  At the heart of data quality, he says, is metadata that explains where the information came from, what it means, when it was updated, and more. This metadata is the interpretation and without it, your facts are pretty much useless.  According to Andrew, "collecting the data is one-half of the problem. It's actually the easier half. The other half of the problem is taking the data that you've collected and sharing it with all the stakeholders that need it in the format they can actually consume and trust".

Andrew admits that there's a fair amount of complexity in the context (i.e. interpretation) of provider data and that it does make for an interesting challenge. However, he thinks the healthcare industry uses this complexity as an excuse for bad user interface design. With better user-interface design, many of the context issues go away.

Another key idea from Andrew is that there's a consumer aspect to all of this. He's not talking about the patient, but rather the provider as a consumer. That is, many providers are paying to have their information kept up-to-date and propagated to sites like Yelp, Yext, and others.  That, coupled with Andrew's real world experience in working with doctors, suggests that they do want this data to be correct and they want people to have access to it. So, we have the need, the desire, and the resources. It's time to give doctors the tools they need to get the job done.

Andrew, co-host Shahid Shah and I discuss all of this and so much more. Here are some highlights:

• Why we should approach provider directory as a data quality problem (3:05)
• How did BetterDoctor get into the provider directory space? (4:20)
• How BetterDoctor's involvement in the AHIP Provider Directory Pilot solidified their pivot (8:25)
• How to know what the right data is and why it's important to share the metadata in support of quality and context (10:12)
• How the industry uses complexity as an excuse for bad user interface design (13:40)
• BetterDoctor's approach to collecting high-quality data (15:52)
• What's the provider's incentive to respond to information requests and keep their data up-to-date? (21:30)
• The often overlooked consumer aspect of this issue is that many providers pay to have their information updated and syndicated to sites like Yelp, Yext and more. They want it to be correct and they want everyone to have it (24:04)
• Why many innovation labs and coding camps are making use of BetterDoctor's API (26:03)
• Should we incorporate credentialing into the provider directory issue right now? (28:30)
• New innovation models like CPC+ and regulations like MACRA may require accurate provider network data as a pre-requisite for getting paid. Do these programs finally give us the incentives we need to solve this problem? (34:30)
• What do you say to providers who look at the BetterDoctor form as more work or another distraction? (38:13)
• BetterDoctor just closed an $11M investment round. What's next? (47:07)

As usual, I had a lot of fun with this one and learned a ton. I hope you enjoy it!

- Don Lee

Check it out on:

http://bit.ly/HCBiz-iTunes 
http://bit.ly/HCBiz-GooglePlay 
http://bit.ly/HCBiz-Stitcher 

Prefer to read it? That's a little weird, but we got you covered!

Download the full transcription here

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About Andrew Kobylinski and BetterDoctor

As Head of Platform, Andrew leads BetterDoctor's data and API business. Andrew has over ten years experience creating new products and bringing them to market at healthcare startups. Creating a solution to inaccurate provider data is his latest passion.

BetterDoctor delivers accurate provider directory data to ensure health plans, health systems, provider groups, and doctors are regulation-compliant and can provide patients with the care they’re looking for.

Learn more on the web: http://betterdoctor.com/

Developers: http://betterdoctor.com/developers/

Email: hello@betterdoctor.com

Twitter: @BetterDoctor

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About the Provider Directory Podcast Series

This episode is part of our ongoing Provider Directory series that aims to dissect the issue from all perspectives, including provider, payer, patient, and regulator. Our goal is to help facilitate an expanded national conversation that drives us towards an open, collaborative industry solution.

Check out all our Provider Directory posts and episodes here!

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Weekly Updates

If you like what we're doing here, then please consider signing up for our weekly newsletter.

---

The #HCBiz Show! is produced by Glide Health IT, LLC in partnership with Netspective Media.

Music by StudioEtar

On this episode, the fourth in our ongoing Provider Directory Series, we continue to unravel the "why" behind provider directory inaccuracies. One major theme that's emerged is that we have a context gap between health plans and providers. That is, even when we're asking the right people at the right time, we might be asking the wrong questions.

Our guest, Ron Urwongse, a Senior Product Manager at CAQH, explains how adding a level of specificity to our questions can yield dramatically different results. For example, if you ask a provider if they work at an office, they may say yes even if there's only a slight chance they ever will (i.e. to cover for a colleague). The tendency, Ron explains, is that providers play defense - they don't want to have a claim denied if they ever do submit one from that office.

By adding some specificity to our questions, we could cut down on the confusion. How often do you work at this office? Or, do you accept new patients at this office? Are bound to yield more accurate results. These follow-on questions help the providers to understand what they are truly being asked. We can add even more context by making sure they know how the information is going to be used. Where do you bill from so that our billing department can process your claims properly? Where should our provider directory list you as accepting new patients?

Ron and I discuss this context issue and so much more, including:

• What is provider data? (2:00)
• Besides demographics, what else do we need to know about providers? (4:00)
• In addition to patients, who else is affected by bad provider data? (5:30)
• We're spending billions of dollars managing provider directories. Why are they still broken? (8:15)
• Is it fair to place accountability on the providers and put pressure on them to resolve this issue? (10:57)
• What are the proposed penalties from CMS for Medicare Advantage plans whose directories fall out-of-date? (11:50)
• Has anyone been fined yet? (12:10)
• Do health plans do a good job of sharing provider information across departments within their own organization?  (12:10)
• Why can't I just go to NPPES? Why aren't the doctors keeping their data updated? (15:00)
• Why do providers (and their groups) report that they work at locations that they don't work at? (17:37)
• Why do providers feel that their data submissions fall into a black hole once submitted? (20:00)
• The typical 5 -doctor practice has 12 contracts and each of them requires 140 data points. That's 8,400 data points for a relatively small practice. (21:20)
• Are the regulators being reasonable in their demands? (23:30)
• How does contracting and reporting at the group-level cause problems for provider directories? (25:30)
• Is there any reluctance to share because of security/privacy/competitive concerns? (29:15)
• How does the expansion of the care team make this problem more complex? (31:40)
• What's happening on the solution side? (33:15)
• How can we foster safe collaboration among industry competitors? (34:10)
• A call to reduce provider burden, while simultaneously raising their accountability. (35:00)
• What is the minimum necessary data set for provider directories? (38:30)
• What is CAQH doing to solve the problem of bad provider data/inaccurate provider directories? (37:00)

I hope you enjoy it!

- Don Lee

 

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About Ron Urwongse and CAQH

Ron Urwongse is a Senior Product Manager at CAQH. Ron guides the cross-functional team responsible for CAQH ProView. Previously, he led product development and operations at Tyrula LLC, focusing on risk adjustment and quality improvement solutions in managed care. At Vecna Technologies, Ron served as a product manager. He also led the development of a billing solution for the Massachusetts Commonwealth Connector, the first state health insurance exchange website. Ron received his MBA from the MIT Sloan School of Management, Master’s Degree in Information Systems Management from Carnegie Mellon University, and B.S. degree in Information Systems from Carnegie Mellon University.

CAQH, a nonprofit alliance, is the leader in creating shared initiatives to streamline the business of healthcare. Through collaboration and innovation, CAQH accelerates the transformation of business processes, delivering value to providers, patients, and health plans.

• COB Smart^® quickly and accurately directs coordination of benefits processes.
• EnrollHub^® reduces costly paper checks with enrollment for electronic payments and electronic remittance advice.
• CAQH ProView^® eases the burden of provider data collection, maintenance, and distribution.
• SanctionsTrack^® delivers comprehensive, multi-state information on healthcare provider licensure disciplinary actions.
• DirectAssure^® helps health plans increase the accuracy of provider directories.
• CAQH CORE^® maximizes business efficiency and savings by developing and implementing federally mandated operating rules.
• CAQH Index^® benchmarks progress and helps optimize operations by tracking industry adoption of electronic administrative transactions.

Learn more:

CAQH Home: https://www.caqh.org/

Provider Data Action Alliance: http://CAQHProviderData.org

Provider Data Tools from CAQH: http://ProviderDataManagement.org

Defining Provider Data Whitepaper: https://www.caqh.org/about/defining-provider-data-white-paper

Twitter: @CAQH

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Mentioned on the Show

JAMA: The Accuracy of Dermatology Network Physician Directories Posted by Medicare Advantage Health Plans in an Era of Narrow Networks

Health Affairs: Secret Shoppers Find Access To Providers And Network Accuracy Lacking For Those In Marketplace And Commercial Plans

CMS Online Provider Directory Review Report

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About the Provider Directory Podcast Series

This episode is part of our ongoing Provider Directory series that aims to dissect the issue from all perspectives, including provider, payer, patient, and regulator. Our goal is to help facilitate an expanded national conversation that drives us towards an open, collaborative industry solution.

Check out all our Provider Directory posts and episodes here!

---

Weekly Updates

If you like what we're doing here, then please consider signing up for our weekly newsletter.

---

The #HCBiz Show! is produced by Glide Health IT, LLC in partnership with Netspective Media.

Music by StudioEtar

The national provider directory discussion is clearly focused on the patients and health plans. It focuses on the patients because they're the consumer of this information and without it, they can't make educated decisions when buying health insurance. The conversation focuses on health plans because they're the ones being held accountable for making the information available to consumers. To effectively address this issue, we also need to take a good hard look at things from the providers' point-of-view. That's what this episode is all about.

We'll talk with Bill Barcellona, Sr. VP for Government Affairs at CAPG, which is a national association that represents physician organizations who practice capitated, coordinated care.  Bill does an excellent job of sharing the providers point-of-view on the provider directory issue and shows us how provider groups can take the lead on cleaning things up. Bill also tells us about California's SB-137 and explains how it's putting pressure on both health plans and provider groups. It's a fascinating discussion that will expand your understanding of this increasingly complex issue. You'll learn:

• What is SB-137? (1:20)
• Where do all the provider directory errors come from? (3:19)
• Who's responsible for provider directory accuracy? Who's accountable? (5:00)
• What does SB-137 call for specifically? (7:45)
• How have providers responded to the accountability placed on them by SB-137? (11:00)
• What is the SB-137 timeline (12:45)?
• Why can't health plans pull accurate provider demographics from the claims? (13:25)
• Why is it beneficial to address this problem on the provider side? (17:30)
• How else are providers impacted by this problem? (19:30)
• When should the health plan go directly to the provider for info? When should they go to the group? Why is there a distinction? (20:40)
• How can inaccurate provider directories lead to FTC/anti-trust scrutiny? 24:50
• How is CAPG working with Gaine Solutions (Sanator) to help providers address the issue? (26:45)
• What is the California Provider Directory Collaborative? (30:30)
• Can a California-based solution scale nationally, or are California's problems unique? (33:00)
• What are the risks associated with a state-wide or nation-wide solution? (34:27)
• How SB-137 and other rules have killed the idea that narrow network details are proprietary information (37:15)
• Defining a public API for master and metadata needed to share information about contracts, networks, products, and providers nationwide.

Or, listen right here:

Prefer to read it? Transcription coming soon!

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About Bill Barcellona

Bill Barcellona serves as the Senior Vice President for Government Affairs for CAPG, overseeing state and federal legislative and regulatory activities for the association in Sacramento and Washington, DC. Bill is the former Deputy Director for Plan-Provider Relations for the Department of Managed Health Care in Sacramento. In that capacity, he oversaw health plan operational issues and handled policy matters for the DMHC. Bill has a Masters in Healthcare Administration from the University of Southern California and serves as an adjunct faculty member at USC and also holds a B.A. in political science and a J.D. He enjoys teaching and lecturing across the country on health care management, operations and policy matters. He has practiced law for 28 years in California and prior to his service at the DMHC he spent 16 years at two major law firms in Newport Beach and Sacramento, primarily as a civil litigator. His current legal experience includes general health law matters with an emphasis in Knox-Keene Act and managed care issues.

Bill is a former Judge Pro Tem in the El Dorado County Superior Court and served as an appointed member of the California State Bar Association Insurance Law Committee. He was previously awarded the 2009 Alumnus of the Year by the USC Health Services Administration Alumni Association, and a 2-year term as a board member of the Health and Human Services Privacy and Security Advisory Board. He lives in Folsom, a small town in the foothills of the California Gold Rush. He has been active in the community for over 20 years, serving as a Planning Commissioner for the City of Folsom, chairing bond measure campaigns to build new schools, serving as an officer of the Folsom Economic Development Corporation and in the past as a Director of the Folsom Chamber of Commerce. Bill currently serves as a member of the USC Price School Health Advisory Board.

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About CAPG

CAPG is the leading association in the country representing physician organizations practicing capitated, coordinated care. Their membership currently comprises close to 300 multispecialty medical groups and independent practice associations (IPAs) across 42 states, the District of Columbia, and Puerto Rico.

Learn more:

http://www.capg.org

@CAPGVoice

Register now for the CAPG Annual Conference 2017 - June 22-24 in San Diego, CA - CAPG's Annual Conference attracts national industry leaders from top medical groups, independent practice associations, hospitals, health plans, and government who come together to learn about the latest and greatest in capitated, coordinated healthcare.

Also mentioned on the show:

California Provider Directory Collaborative - The California Provider Directory Collaborative Community of Practice is an online forum dedicated to supporting a statewide dialogue on critical provider data and directory issues and to inform regulators as they implement SB 137. Please contact us at ProviderDirectory@manatt.com if you have any questions or would like to learn more.

CAPG White Paper: Provider Directories - Driving Accurate Lists for Consumers

Sanator Provider Registry by Gaine Solutions

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About the Provider Directory Podcast Series

This episode is part of our ongoing Provider Directory series that aims to dissect the issue from all perspectives, including provider, payer, patient, and regulator. Our goal is to help facilitate an expanded national conversation that drives us towards an open, collaborative industry solution.

Check out all our Provider Directory posts and episodes here!

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