Feed Claims Systems with Robust, Accurate Provider Data–Avoid Noncompliance & Regulation Penalties


By Rebecca Jones | February 7, 2020

DALLAS, TX, February 7, 2020 – The implementation of the Affordable Care Act (ACA), coupled with the rise of value-based-care, has seen contracted provider networks, from ACO’s, to CINs, to Narrow Networks, struggle with their ability to properly serve their populace with accurate provider data, resulting in increased specificity on both federal and state level regulations for provider directories.


This subject was previously analyzed in a white paper “Provider Directories: Litigation, Regulatory and Operational Challenges” by Berkeley Research Group. Their paper provides a good resource for background reading and further examination into the struggles that surround provider directories.


These regulations, which constantly evolve, differ between states, adding another layer of complexity to an already rigorous process. So, what goes into the evaluation of these network directories?


The National Committee of Quality Assurance (NCQA), the nation’s largest accreditation body, scores directories based on several elements, including:

  • Providing an online provider directory that displays:

- Name, Specialty, Location

- Affiliations, Certifications

- Whether or not they are accepting new patients

  • Updates provider data within 30 days maximum of receiving new information

  • Offers search functions within the directory

In addition, Centers for Medicare and Medicaid Service (CMS) federally regulates that…

  • All provider information must be “easily accessible” and publicly available on websites

  • Updated frequently, at least monthly

  • Provides provider locations

  • States whether or not providers are accepting new patients

  • Provides provider specialties


The consequences of not following these regulations can be costly, as consumers rely on this information to receive appropriate care. Aside from underserving their population, directories can face fines of up to $5,000 per day, per incident for noncompliance with CMS or state level regulations.


Even with stringent regulations, and the high stakes of healthcare, provider directories continue to be problematic for the health systems and health plans that manage them.


Phynd presents a solution. Phynd 360, an innovative and unique provider data management platform, serves as a central hub for all provider data. Phynd optimizes provider data – people, places and services – for use in EHR, Marketing and Claims systems via platform tools which offer provider enrollment, management, search and outreach across the enterprise.


Networks, both broad and narrow, benefit from Phynd. Phynd’s one-of-a-kind platform continuously curates and feeds updated provider information into your provider directory for use on public facing sites and internal use. Phynd ensures you accurately track and report out provider health plan and network participation and share that data for provider search. Phynd manages provider and care location participation in:


  • Commercial payor and health system plans

  • Medicare and Medicaid programs

  • ACOs and Clinical Networks


Contact Phynd to learn how Phynd helps your provider directories stay in compliance with state and national regulation, while providing a superior consumer experience.


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