Health Plan Directory Accuracy Improvement Case Study

This case study outlines the efforts of a large national health plan to enhance the accuracy of its directory data for Medicare Advantage plans. The primary objective was to reduce audit risk and improve member satisfaction. The health plan faced challenges with costly provider outreach efforts, which involved making 1.2 million phone calls to confirm provider locations. Despite some improvements, this approach was resource-intensive and unsustainable. To address these issues, the plan partnered with CAQH to implement a pilot initiative in Texas, replacing phone calls with automated system-generated messages for providers with outdated records. After three months, an internal audit revealed that 76% of providers had completed profiles and attested to their data, leading to the removal of 20,000 outdated records. The initiative resulted in an 84% accuracy score for the provider directory, significantly exceeding the national average and enhancing provider satisfaction.