Industry Insights

Centers for Medicare & Medicaid Services (CMS) and the Department of Health & Human Services (HHS) have released new rules, effective June 30, 2020, that will affect Provider Data Management teams who commonly use credentialing databases. Provider payor enrollment and delegated credentialing departments will likely see the greatest impact. Depending on how Provider Data Management teams enter data, Medical Staff Credentialing departments or the Central Verification Office (CVO) will also be impacted. CMS imposed fines can be imposed as early as summer 2021.

As part of the new requirements for Provider Directory API, Patient API, and Payer-to-Payer feed, some CMS regulated insurances are required to standardize data elements of provider rosters. This is, among other things, so patients and their providers can find other providers easier, to help with coordination of care. It is imperative that data within payor enrollment/credentialing databases be managed with strict data standards, since this data is what feeds payor rosters.

Two of these elements are:

• Provider Type/Specialties
• Location/Address

Both Type and Specialty will have to conform to The National Uniform Claim Committee’s (NUCC) standards. Which means the taxonomy and specialty codes within the current database should either match, or be mapped to, what is available from NUCC. Electronic Health Records sources also need to meet this requirement.

In addition to the taxonomy code, data owners will need to assure specialty names truly meet the standards, such as having NUCC’s “Physical Medicine & Rehabilitation” versus using the older term “Physiatrist” or “Physical Medicine and Rehabilitation.” The same is to be said for checking provider type, which NUCC defines as:

• A major grouping of service(s) or occupation(s) of health care providers. For example: Allopathic & Osteopathic Physicians, Dental Providers, Hospitals, etc.

NUCC is updated twice a year and is available via licensing through the American Medical Association, as published through the Washington Company, or directly via www.nucc.org.

Additional consideration should be made toward evaluating if the current tools used to manage provider data include the use of modern-day Credentialing Products. Throughout the industry, it is still observed that healthcare organizations are using insufficient tools (e.g., Excel, Access, CRMs not enabled with minimum automations, and/or paper processes). The outcome results in increased manual processes, additional staffing to manage workflows, increased liability, risk, and re-work.

For the past ten years, the data management demands on enrollment professionals have continued to rise with no signs of relief. The following example pertains to CMS Interoperability requirements and it applies to the demands of most payers.

For Provider Directory API requirements, locations must be defined by Physical, Postal, or both. To meet the above requirements, not only will address matching, standardization, and validation be required, but they will also be critical to the delivery of the standardized API requirements.

Please note, while the United States Postal Standards (USPS) are not a firm requirement for several standards, it’s nearly impossible not to use USPS in matching records and validating if the address is a physical location.

Many organizations are working to meet the challenge of identifying which data source contains the Master Location values, including both names and remaining data elements. As with many industries, identifying “golden” records for location values often requires multiple data sources. Many organizations choose to partner with licensed data sources to provide Healthcare Organization (HCO) data sets containing taxonomies by location. Popular among healthcare for defining the standards are sources such as IQVIA (subsidiary of Dunn and Bradstreet), Definitive Healthcare, Lexis Nexis, Quest Analytics, and so on.

A typical sample of healthcare names found in contributing data sources—which is why Master Locations are needed—include:

• Pediatrics R Us
• Pediatrics-R-Us
• Peds R US

These rules are the HHS Office of the National Coordinator (ONC) for Health Information Technology’s 21st Century Cures Act: Interoperability, Information Blocking, and the ONC Health IT Certification Program Final Rule; and CMS’s Interoperability and Patient Access Final Rule. Both acts have narrowing windows to conform to new data standards, which must be in place by 2021 and beyond.