Tuesday, April 05, 2016

#ONCPDW #PDWorkshop Part 2 – Provider Directories- Post-ACA

Sarah Summer, Deputy Director, Public Policy – Blue Shield of California

Provider Directories from Consumer perspective.

2016 – 12.7M people purchased insurance through Health Insurance Exchange aka Marketplace.

Newly Insured are largely subsidized. Lower income participants.

Higher Churn than other insured populations.

  • Mainly leaving for Employer plans


  • Keeping costs reasonable
  • Making complex products in simple terms
  • Higher rates of churn
  • Government oversight and regulations

Multiple regulators sometimes in conflict.

Provider directories are important but hard to get right.

Consumers use them to choose plans.

But there is:
– Provider confusion
– Quickly changing data
– Outdated systems and processes
– Reliance on factors outside a plans control.

Data needs to be updated on weekly or monthly basis. eg. Accepting patients.

Currently using Fax to maintain information

Federal Regulations

  • Qualified Health Plans
  • Medicare Advantage
  • Medicaid “Mega-REg”

State Regulations

  • SB 137
  • Covered California
  • CDI Network Adequacy Regulations
  • DHCS Requirements

Provider Directory Components:

  • Provider Portal
  • Database
  • Consumer Portal

People want to fix consumer web-site first but you need to get the underlying data accurate first.

How to fix

Provider Shared Responsibility

  • Carrot – make it easier
  • Stick – Consequences for not updating – Contract requirements (SB137 enables withholding payment for up to 1 month)

Leverage Efficiencies

  • Use Existing Sources
  • Identify inconsistencies

Create a single source of Truth

  • Master Database

AHIP Provider Directory initiative

  • Improve accuracy
  • Reduce noise
  • Evaluate options


  • Consumer Search tool (Garbage in, Garbage out)
  • Provider Data Federation
  • **** Shared Central Provider Data Utility

Availity and Better Doctor are recommended Vendors

Currently in Pilot.
Vendor selection in Q4 2016.

Presenter: Sarah Summer

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