What is Provider Data Management?
Provider Data Management (PDM) utilizes technology, services, and procedures to enable healthcare organizations to effectively collect, aggregate, and manage comprehensive information about the providers who supply services in their ecosystems. This data is used for many purposes and begins as providers join the healthcare organization through the credentialing process. This procedure is used to verify that providers are qualified to provide care for patients. Credentialing is an ongoing process since certain qualifications need to be renewed periodically.
Table 1 references the types of information required in the credentialing process. The data required to support this process comes from the provider and other independent sources. If credentialing or recredentialing data is not accurate, healthcare organizations may allow unqualified providers to care for their patients which creates a significant risk for the patient and provider organization. CMS now issues fines for inaccurate network directory data, which can also lead to dissatisfied patients. Incorrect data on claims can lead to additional claims processing work, and/or denials, resulting in lost revenue.
Provider information will be used to publish network directories to make it easier for patients to find providers who are best able to provide the care they need. Usually this includes a provider’s specialty, office locations, office hours, telephone numbers, accepted insurance plans, and whether they are accepting new patients. Much of this information comes from the provider or their administrative staff.
Finally, to be reimbursed for the services they deliver, providers must supply accurate information so that claims can be processed and payments received. In many instances, this will include service locations, National Provider Identifiers (NPI), banking information, and copies of the provider’s W9. This data is usually given by the provider or their administrative staff.
Provider Data Management is challenging because some data are static, not changing, while other data are dynamic and may only occasionally change. Additionally, there is no single authoritative source for this information, making it very complex to manage. In many cases, it is the provider who is responsible for supplying the data and their priorities tend to focus on patient care rather than administrative tasks. The result can be inaccurate data about the provider, which can lead to costly consequences.
A good provider data management solution will mitigate the risks to patients and minimize the financial impact to an organization.