PROVIDER DATA ACCURACY ASSESSMENT TOOLKIT

QUEST ANALYTICS® Provider Network Management

Healthcare policies are continually evolving, dictating a shift toward more precise methods for improving provider data accuracy. As these regulations advance, the complexity of provider data accuracy audits increases. This raises critical questions:

• Do your current systems and processes comply with the new requirements?

• Can your strategy adapt to future regulatory changes and market demands?

• What adjustments are necessary to ensure your approach remains compliant and successful?

Use this guide as a roadmap to evaluate and refine your strategies, identify gaps, and create actionable plans to meet regulatory requirements and achieve market leadership.

SECTION 1:

Getting Started

Attestation Involvement: Who is primarily involved in your provider outreach and attestation process? Please select all that apply.

Policy Manual: Does your company have a Provider Directory Policy and Procedure Manual?

New Solutions: Have you recently implemented new solutions to improve provider data accuracy and network adequacy?

Program Compliance: Which programs and agencies are relevant to your organization regarding provider directory accuracy requirements and audits? Please select all that apply.

SECTION 2:

Provider Verification Cycle

Outreach Frequency: Are you conducting outreach to verify provider information every 30 to 90 days?

Provider Attestations: What percentage of provider attestations do you receive in 90 days or less?

Outreach Schedule: Is the outreach cycle for a provider or group roster based on the last attestation date?

Location-Centric Outreach: Do you use a location-centric approach that focuses on confirming the status of all providers at a specific location?

Outreach Methods: Which communication channels are used to request provider updates? Please select all that apply.

Tailored Outreach: Does your outreach and verification program offer different approaches based on the practice size?

SECTION 3:

Provider Outreach Metrics

Policy: Provide metrics on provider outreach and verification activities.

Outreach Metrics: Do you record outreach metrics at multiple levels?

Outreach Eligibility: Do you track the percentage of providers eligible for outreach within your total provider network?

Outreach Status: Do you track the network percentage of outreach attempts and successful completions?

SECTION 4:

Data Management Handling Questionable Provider Attestations

Requirement: Establish a process to remove providers from the directory if they don’t verify their data within the required timeframe.

Data Review: Do you review the verified data to identify any questionable responses?

Flagging Protocols: Are there established protocols to flag questionable responses for further investigation?

Research Process: Is there a process in place to investigate questionable responses?

Directory Inclusion: Do you incorporate providers and facilities with questionable responses into your directory while investigating their information?

Review Timeframe: Is there a set period to review and address questionable responses?

External Validation: Do you use external databases or third-party verification services to cross-check and validate provider information?

Communication Protocols: Are there communication protocols for informing providers about questionable responses and requesting additional information?

Escalation Procedure: Is there an escalation procedure in place for handling instances where questionable responses remain unresolved after initial investigation?

Audit Trail: Do you record all actions taken on questionable responses?

SECTION 5:

Communicate Updates

Requirement: Update the provider directory and communicate changes to members in the required timeline.

Member Communication: Do you inform members of provider network changes within the regulatory timeframe?

Directory Updates: Do you update the provider directory within the regulatory timeframe?

SECTION 6:

Reporting

Do you monitor provider data accuracy trends in your network?

Please indicate all the levels you assess.

Network Level
Service Area Level
Provider Specialty Level
County Level
Other

SECTION 7:

Risk Management and Partnerships

Provider Contracts: Are stipulations included in your provider contracts that mandate periodic data review and validation responses from providers?

Shared Risk Framework: Do you have a shared risk partnership to collaboratively manage risk?

Partner Compliance Reviews: Are your partner organizations subject to periodic evaluations to ensure they adhere to compliance standards?

Collaborative Management of Provider Information Risks: Do you and your partners jointly manage the risks related to the accuracy of provider information?

Enhance your provider data accuracy with our dynamic, transparent, and proven approach.