Provider directory APIs should be more than an afterthought
By David Finney
In a season of anxiety, it might be easy to overlook the rising worry about approaching deadlines related to the Interoperability and Patient Access Final Rule. But it’s certainly there. A survey released by the eHealth Initiative last month underscored that, distracted by COVID and other priorities, many health plans and Medicaid agencies are fretting about their ability to comply on time.
For example, according to eHI, 78% of payers reported that their ability to get ready for the Interoperability Rule has been hindered in some way by COVID. Most of the industry is probably hoping for further enforcement discretion (e.g. delays) from the federal government. Whether that comes or not, it’s patient access that is most on the plans’ minds.
No doubt the patient access component of the Interoperability Rule is its most daunting. Making sensitive patient data available via API is a significant technical challenge, even for many larger organizations. Complexities associated with consent management and privacy and security must be navigated. The risk profile of launching such a service is high.
It’s understandable, then, that many plans would pick a technology vendor with expertise in patient access as their one-stop-shop for a solution to the entire Interoperability Rule. Many of those vendors are offering to throw in a provider directory API solution as a bonus. But there’s peril for plans following this path of least resistance. Here are three reasons why implementing the provider directory API should be a strategic investment more than an afterthought.
1. Choosing a solution wisely can address perennial challenges such as provider credentialing and network management.
According to CAQH, managing provider data is a $2 billion-per-year exercise—and still often an exercise in futility. Additionally, CMS has the authority to fine health plans up to $25,000 per Medicare beneficiary for deficiencies in Medicare Advantage plan directories and up to $100 per beneficiary for errors in QHPs in the ACA exchanges. Beyond the immediate financial implications, poor provider directories create barriers to care for members, result in lost revenue for plans, and cause delayed and denied claims. Simply adding a thin layer of FHIR compliance to an existing provider dataset is a missed opportunity. A more robust, purpose-built provider directory solution that leverages reference data from a broad range of public and proprietary data sets, along with sophisticated matching and cleansing algorithms, can result in cleaner, curated provider data to inform a plan’s upstream business processes. Reference data allows plans to benefit from the “wisdom of the crowd,” capitalizing on primary-source outreach and data quality improvements to directories made elsewhere instead of constant manual effort.
2. Plans subject to the Medicaid Managed Care 2020 Final Rule must meet additional, more complex provider directory requirements.
The Interoperability Rule and the new MMC Final Rule are designed to be complementary. The Interoperability Rule requires publishing an API (digital endpoint / machine usable) that returns at minimum a pretty limited set of provider attributes, while the MMC Final Rule requires plans to publish an online and mobile-friendly directory (human usable, including by members with disabilities) with a more extensive set of provider attributes. The same underlying provider data model can support both of these requirements, serving up provider data for both the API and the mobile-friendly web interface. Many plans that offer a provider search function on the web today have not optimized it for mobile to the extent CMS is requiring; further, without a detailed understanding of the MMC Final Rule, patient-access vendors may deliver solutions that do not comply with it either. Maryland’s Medicaid program is already utilizing Leap Orbit’s solution, Convergent, to comply with the CMS Interoperability Rule. The provider directory is being deployed in partnership with Leap Orbit’s longtime client CRISP, a regional health information organization that is Maryland’s state designated health information exchange (HIE). CRISP has contracted with MedChi, the Maryland State Medical Society, to provide data stewardship services for the provider directory.
3. Implementing a cutting-edge provider directory solution doesn’t have to be a huge technology project.
Many plans and Medicaid agencies are accustomed to costly, months-long custom software implementations with a waterfall of complex technical and functional requirements. There are many reasons why vendors continue to pitch such projects, not least because they can be highly profitable. But this need not be the case to implement a cutting-edge provider directory. Just as companies like Salesforce and Google have revolutionized other sectors with cloud-native data management platforms, next-generation provider data management platforms like Leap Orbit’s Convergent provider directory can be deployed and configured in a matter of days, dramatically shortening a customer’s time to value. Choosing such a platform also eliminates much of the execution risk inherent in the implementation of custom enterprise software.
Leap Orbit has created the perfect tool for your health plan to immediately comply with the CMS Interoperability and Patient Access Final Rule as well as the 2020 Medicaid Managed Care Final Rule. Our healthcare provider directory, Convergent, bridges the gaps in fragmented, poor quality provider listings across institutions, systems of care and technology platforms. This data-as-a-service solution uses proprietary matching and cleansing algorithms to sift through and unify provider data from large public and proprietary data sets. The fully FHIR 4.0 compliant suite of APIs and mobile-friendly user interface provide health plans and Medicaid agencies with clean, curated and always up-to-date network data. Don’t wait, start working on directory compliance now that works as a sure investment in the future.
