# 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?

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