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Do once, use many: a sensible approach to provider directory verification

By Mark Borca

SKYGENUSA Powering Healthcare for the Digital Age


In 2015, the State of California enacted SB137, which as of July 1, 2016 requires all health plans in the state to “publish and maintain a provider directory or directories with information on contracting providers that deliver health care services to the plan’s enrollees, including those that accept new patients.”

To maintain compliance, each provider must enter a standardized set of data for every plan they work with. They are also expected to update their information in the directory on a regular basis, along with when there is a change in status such as now accepting new patients when that wasn’t the case before.

While making current, accurate information about providers is a good thing, the way the system is designed is a logistical nightmare for providers. While there may some exceptions somewhere, providers typically participate in multiple networks in order to broaden their potential patient base. If a provider is part of 10 networks, the law will require them to enter the exact same information 10 times. And they will have to make every update 10 times as well.

Of course, more data entry takes time away from patient care. It also increases the likelihood of human error. Since California tends to lead the way for legislation that is eventually adopted throughout the U.S., it’s easy to see where any issues generated by SB137 will quickly be multiplied by 50.

There is a simple solution to this dilemma that will give the states what they need while also greatly reducing the administrative burden on providers. It’s building a single, universal, automated Provider Verification Tool that contains all the information required for directories across all 50 states.

Under this system, providers would access the Provider Verification Tool and upload their information once rather than having to enter the same information one at a time for each health payer. When the payers are building their directories, their systems would automatically match the National Provider Identifier number to the listing in the Provider Verification Tool and download the information.

If a provider updates his or her information in the tool, the directory is automatically updated as well, ensuring the directories are always complete and accurate.

There are some challenges, not the least of which is getting all of the states to agree on the formatting of the data to ensure providers only have to enter their information once. On the other hand, if some states require more or different information, those fields could be added, and only used if the provider is licensed to practice in one of those states. In addition, some entity will be charged with maintaining the technical aspects of the Provider Verification Tool to ensure it interfaces easily with payer systems and is available with zero downtime.

The benefits, however, well outweigh any challenges. Providers will be relieved of 99 percent of the administrative burden this law will create. Essentially, it will be “one and done” for them.

Payers will have access to the data they need to meet state requirements on-demand rather than having to expend time and resources chasing after providers to update their information. This will not only reduce their costs of building a provider network; it will also help reduce their risks of being out of compliance with the law.

Members benefit as well, as they will have instant access to a real-time view of their in-network providers, by specific product, and whether that provider is accepting new patients.

Finally, the states themselves would benefit because compliance would be greatly simplified, reducing their need to expend limited funding on enforcement. It would also give them a shining example to point to of how they are using technology to improve the delivery of healthcare for their citizens.  

It all boils down to one simple question: why build and maintain many separate databases when it’s possible to put all the information they will ever need into a single Provider Verification Tool? The technology and the mindset exists. All that’s required now is the will.

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Mark Borca

Mark Borca

As Vice President of Business Development for SKYGEN USA, Mark Borca is the initial point of contact for new clients and prospects, with responsibility for ensuring clients understand the synergies and other advantages to be gained by working across the full spectrum of the SKYGEN USA family of companies. He is also responsible for making current clients aware of new product offerings that will help them increase revenue, become more efficient, and serve their members more effectively.

Mr. Borca’s 20 years of experience in benefit management, with a specialty in government programs that includes provider network contracting, client management, provider compensation, and risk management strategies, gives him a unique understanding of the challenges clients face in an evolving healthcare market. Additionally, the extensive knowledge and experience he has accumulated about Medicaid managed care programs, both at SKYGEN USA and previously at Doral Dental, makes him an invaluable asset throughout the business development cycle.

Over the past 20 years, Mr. Borca has proven his ability to deliver results across a variety of roles. It is what makes him ideally suited to working as a strong advocate for both SKYGEN USA and its clients.

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