Pursuant to 42 C.F.R. §422.111, CHPW must provide clear and accurate information to beneficiaries regarding CHPW’s provider network.
In a recent CMS audit, CMS verified a variety of data in the directory, including if the clinic name matched the name and location listed in the directory, and if providers were accepting new patients for the plan. The results showed a deficiency score of 57.98% for CHPW (the error rate was 41% among all 54 plans audited by CMS).
The main root cause is due to providers leaving the clinic and not notifying CHPW. Per CMS, it is CHPW’s responsibility to ensure the accuracy of our provider data.
CHPW is reviewing 100% of our contracted providers at a minimum of once annually to ensure accuracy. There are over 30,000 contracted providers in CHPW’s network. To ensure CHPW’s provider directory is accurate, CHPW must identify solutions to improve accuracy, such as performing self-audits of directory data, and working with group practices to ensure that providers are only listed at locations where they accept new patients.
Improvements CHPW has made
- CHPW lists every contracted provider accepting patients in our directory.
- Looking at automated solutions to validate an average of 7,500 providers per quarter.
- Staff conduct phone interviews and review electronic rosters for validation in order to manage the volume of providers in the CHPW network.
- CHPW will host provider focus groups to gather ideas for process improvement in collecting up to date and accurate provider information.
- Work is being done today to enhance CHPW’s provider portal to allow electronic submissions of provider updates.
- Providers with no claims activity for 6 months will be termed and removed from the directory.
- Provider education to ensure providers know how data will be used and protected.
- Surveys show the highest completion of validation was conducted via telephone. What is your preferred method of contact from CHPW (phone, email, fax, other)?
- What ideas do you have to share provider data?
- Would creating a standard provider roster be helpful? We use one for our delegated provider groups today for consistency.
- Contractual requirement to notify CHPW of provider terms 120 days prior to termination or as soon as the provider notifies the group the provider will be leaving, whichever is later.
- Provide Culturally & Linguistically Appropriate Services (CLAS) detail to CHPW (race, ethnicity, languages spoken).
Provider Rosters, Adds, Changes and Terms should be sent to CHPW via email: firstname.lastname@example.org