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The Challenge

Inaccurate provider data can significantly impact the operations of a Third Party Administrator (TPA) in a number of critical ways:

  1. Reduced auto-adjudication rates
  2. Increased manual claim processing
  3. Higher 1099 fees

It is estimated that 2% to 3% of the US provider population has some form of change in their demographic information in each month. Over the course of a year, this can mean 24% to 36% of your healthcare database may be inaccurate.

2% – 3% of provider demographic data changes on a monthly basis.

The Solution

In 2016, HealthLink Dimensions engaged with a regional TPA to evaluate the health of their provider master database. We analyzed a small provider database of 114,000 provider records for inaccuracies and missing data elements.
Within 5 business days our data services team generated a detailed analysis which;

  1. Identified duplicate providers.
  2. Matched and analyzed the database for unique provider counts and, inaccurate data.
  3. Highlighted provider records which should be questioned for processing.

Listed below is a sample of the results:

Estimated # of Unique Providers of Matched Records after deduplification 23,864
Provider Status Distinct Count
     Active 23,261
     CMS Deactivated NPI 232
     In Research 121
     Retired 34
     Deceased 13
     Unknown 12
     Inactive 7
     Non-Patient Practice 2
     Temporarily Out of Practice 2
DEA Number Expired 524
OIG Federal Sanctions 24 24
State License Sanction (in any State) 272 272
Expired State Licenses 770 770
NPI Incorrectly Identified as Facility (Entity Type Wrong) 151 151
Invalid NPI Number 108 108
Potential Incorrect Name 255 256
Potential Duplicates 5,541 5,541
Potential Incorrect Address 10,410 10,410

The Results

Resulting Value for the Client:

  1. The client was able to identify and eliminate as inappropriate 2% of the claims as retired, deceased, and state/federal sanctioned providers.
  2. They eliminated claims costs for an additional 1% of the claims that were no longer eligible for CMS Medicare/Medicaid payments.
  3. Improved operational efficiencies by appending missing information or correcting inaccurate information including state license, DEA and NPI numbers, names, and addresses.
  4. Increased auto-adjudication rates through the reduction of duplicate entries.
  5. They increased their overall data accuracy by 43%.
  6. They generated additional plan savings by reducing inappropriate and inaccurate medical payments.

+43% Overall Data Accuracy Increase

Due to the impact HealthLink Dimensions was able to provide, the client engaged the company to provide monthly updates to the new Master Provider Database to ensure ongoing accuracy, administrative savings, and medical cost savings to their clients. As a Third-Party Administrator service, whether you are supporting a localized, regional client, or a national insurance provider, effectively managing provider demographic data can improve your efficiencies, eliminate unnecessary plan costs, and ultimately enhance your ability to keep clients and generate new business.

About HealthLink Dimensions

HealthLink Dimensions provides healthcare data solutions to healthcare and life science organizations to improve master data management, compliance and marketing initiatives. Leveraging the largest multi-sourced database of active practicing healthcare professionals, HealthLink Dimensions develops customized data solutions to help clients reach their target audience, enrich their business data, optimize claims processing, meet compliance requirements and solve master data quality problems.

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