CMS Connect Login:



Login Assistance

TURN TO BLOCKCHAIN

How state network adequacy laws are pressuring insurers to improve health provider directories
By Bruce Japsen

HEALTH INSURANCE companies grappling with new state and federal adequacy rules are turning to blockchain technology to improve inaccurate physician directories. The use of blockchain is best known for developing and powering bitcoin or forms of cryptocurrency with the technology’s encrypted and secure technology that protects information.
But insurers and other healthcare companies known for their inability to keep physician directories up-to-date are turning to blockchain to secure data and distribute it securely in an encrypted ledger to make sure the most current information is available in health plan provider directories. “The idea is that we use a blockchain as a way to streamline the back office operations of the payers,” Mike Jacobs, senior distinguished engineer with the Optum healthcare services unit of UnitedHealth Group, the nation’s largest health insurance company, said in an interview.
UnitedHealth and its Optum unit have partnered with rival health insurer Humana, Quest Diagnostics and Multiplan to apply blockchain technology to improve inaccurate doctor directories. Those involved in the pilot hope the use of blockchain technology will avoid the all too common problem that occurs when a claim comes through from the provider and it mismatches with the information the insurance company has in its provider directory.

Illinois Network Adequacy Law Pressures Insurers
Inaccurate provider directories have triggered a parade of legislation in states across the country to improve networks. In Illinois, for example, new state law requires health insurers to have accurate provider directories and that they be updated regularly (see “Accurate Provider Directories Now Mandatory”). “A network plan shall post electronically an up-to-date, accurate, and complete provider directory for each of its network plans,” Illinois’ Network Adequacy and Transparency Act says.
The federal government, too, is answering complaints of doctors and patients in their pleas for accurate medical care provider directories and is now penalizing insurers for inaccurate medical care provider directories. Earlier this year, for example, the Centers for Medicare and Medicaid Services (CMS) found 52% of Medicare Advantage plan provider “directory locations had at least one inaccuracy.”
As regulatory pressure from the federal government and state legislatures like Illinois’ intensifies, health plans and those companies that create provider directories say they are spending more time and money to fix them. “With increasing state and federal requirements relating to provider data maintenance and quality, tackling the high cost and redundancy in this space is a logical starting point,” MultiPlan’s vice president of operations David Murtagh said of the pilot with UnitedHealth, Optum, Humana and Quest.
“Maintaining over one million providers in our networks, MultiPlan has developed broad perspectives on the process and nuanced insight into the various provider types, while continuing to invest in systems and processes to support high quality data,” Murtagh added. “We’re looking forward to exploring how blockchain technology can make the process more efficient while reducing costs, ideally to build investments that can enhance the provider and patient experiences.”
Health plans with out-of-date information can cause patient claims to be unpaid and administrative headaches for physicians and their office staffs. The use of blockchain technology will hopefully avoid the all too common problem that occurs when a claim comes through from the provider and it mismatches with the information the insurance company has. “That happens because there are two islands of information and there’s a need for reconciliation,” Optum’s Jacobs said. “We envision the possibility of effecting change at scale.”

Poor Data Costs Health System $2 Billion a Year
The mismatched medical care provider data happens when health insurance companies, health systems, physicians, diagnostic test companies and others maintain separate provider lists or directories. Those involved in the pilot cite industry estimates showing more than $2 billion is spent each year “across the health care system chasing and maintaining provider data,” UnitedHealth Group and other companies involved said in a joint statement.
The UnitedHealth-Humana-Quest pilot will examine how sharing data across health care organizations on blockchain technology can improve data accuracy, streamline administration and improve access to care, the companies involved say. The pilot will run over the summer and the companies hope to report their findings in the fall.
“With the explosion of health data, organizations need better ways to share and harness information to yield clinical and economic value,” Lidia Fonseca, Quest Diagnostics chief information officer, said. “We are connected to more than 650 (electronic health record) platforms and a majority of health systems and physicians in the U.S., so we bring a unique level of insight into how to connect people and organizations across health care. We look forward to sharing these insights with our alliance collaborators as we jointly explore blockchain’s potential to improve health care data exchange.”

Document Actions

Upcoming Events

ALL UPCOMING EVENTS…

Join CMS

Why join?  The Chicago Medical Society offers many benefits, including career placement, advocacy, networking, and member to member collaboration. Click here to explore all the benefits of membership.

CMS Connect

CMS Connect is an exclusive community that allows members to discuss the issues impacting their practices today. Visit CMS Connect today.