Building A More Accurate, Efficient Healthcare Landscape
Curatus, a progressive healthcare provider data management company, has made significant strides in addressing the pervasive issues of incomplete, inaccurate, and rapidly outdated provider data within the healthcare industry. By leveraging deep technical expertise, Curatus has streamlined the handling and enrichment of large provider datasets, developing effective solutions for Medicare, Medicaid, Exchange, and commercial health plans. This approach enhances operational efficiency and significantly reduces administrative costs and revenue leakage.
“Ironically enough, the number one source of bad information about healthcare providers is the providers themselves,” Curatus CEO Mark Fabiano said. “That’s because providers are ill-equipped and simply not staffed to stay on top of data across all of the [provider] entities with which they are affiliated; not to mention the many payers they’re contracted with. The logistical challenges are overwhelming for their limited staff.”
To lessen this burden, Curatus leverages AI and other prevailing technologies to streamline administrative tasks and improve the provider data quality that is so critical to health plan operations. Healthcare provider entities, in turn, can better allocate personnel focus and ultimately deliver more efficient and effective healthcare services.
The cornerstone of Curatus’s innovation lies in its SaaS platform, ProviderLenz. This technology-enabled solution integrates big data and AI to manage provider data more effectively, tapping into myriad sources of continuous streaming provider-reference data to ensure the most accurate and complete provider data at all times. By doing so, ProviderLenz ensures the consistent and up-to-date provider data across all operational areas within a health plan relying on it. This meticulous curation of data is crucial for maintaining accurate provider directories, ensuring timely and accurate claim payments, medical management, prior authorization, risk and quality analytics, etc.
ProviderLenz also automates the CMS-required quarterly surveys of contracted providers, updating information seamlessly. Such automation reduces the administrative burden on providers, enhancing data accuracy and completeness. Inaccurate provider data has significant repercussions, as evidenced by CMS’s findings, where 52 percent of provider location data had errors in a second-round review of MAO provider directories. Such inaccuracies can lead to substantial fines and penalties for health plans, not to mention the added costs of manual claim adjudication and appeals due to incorrect data.
Consumers bear the brunt of these inaccuracies, often struggling to find providers within their network. CMS’s recent review highlighted that 45.1 percent of provider directory locations were inaccurate, with issues ranging from providers not accepting new patients to incorrect phone numbers and locations. These inaccuracies can result in fines reaching up to $25,000 per Medicare beneficiary for issues in Medicare Advantage plan directories — and up to $100 per beneficiary for errors in plans sold on HealthCare.gov. Additionally, states can also impose their own fines and sanctions, further stressing the importance of accurate provider data.
Curatus addresses these challenges head-on with ProviderLenz’s unique, AI-enabled data-scoring model. This algorithm set generates an ‘Accuracy Confidence Level’ (ACL) score for each piece of provider data. When a low ACL score is detected, the platform automates the outreach process to providers to correct the information, thus minimizing the burden on providers while ensuring data accuracy. This proactive approach not only builds accurate provider data for all use-cases, but also instills confidence in the data used by health plans.
The financial impact of inaccurate provider data is substantial. The commercial healthcare industry spends approximately $2.1 billion annually on maintaining provider databases, with manual claim adjudication and appeals adding $5 per member per year due to inaccurate data. Inaccuracies in provider directories can also lead to significant costs for health plans.
“It’s important that every healthcare dollar spent is spent wisely with the highest amount of it actually paying for healthcare services – not just supporting administrative processes associated with it,” Fabiano said.
Curatus’s comprehensive approach to provider data management addresses these financial and operational challenges and supports better patient outcomes. Accurate provider directories are essential for ensuring that patients can find the care they need within their network, reducing the risk of out-of-network charges and improving overall satisfaction. By continuously monitoring and curating provider-referenced data, Curatus ensures that health plans can meet regulatory requirements and provide accurate, reliable information to consumers.
“There’s regulatory impact on every aspect of a healthcare transaction,” Fabiano said. “So the accuracy of provider data is so critical. We aim to streamline that and boost administrative simplification so that the public can get the best care for their healthcare dollar.”
