The Financial Implications of Provider Data Management

The Financial Implications of Provider Data Management

Sep 22, 2020
  • Author:
    Noelle Abarelli

This blog post is based on an industry insight webinar - The Financial Implications of Provider Data Management; presented by Sorin Davis from CAQH and Cheryl Cisneros at VerityStream.

In the ever-growing world of medical credentialing and privileging, one thing is for certain: provider enrollment is where the financial component of a health system resides. In fact, one could say that issues with enrollment related to poor provider data management are where the majority of unnecessary cost is accrued, which means it also provides ample opportunities for improvements. To better understand the financial implications related to provider data management, let us define three ways organizations can suffer financially:

Claims On Hold – When claims are delayed awaiting confirmation of enrollment from the payor.

Claims Denied – Claims that have been denied by the payor.

Claims Written Off – Claims that have been written off because of a delay in enrollment timeframes, which makes the claim ineligible to be paid.

Oftentimes, the majority of administrators in the provider data management field do not track claims that are written off, which means they don’t have accurate knowledge of how many dollars their organization is losing. A 2020 survey we performed on the financial implications of provider data management found that organizations have millions of dollars that are on hold for a variety of reasons, such as processing delays.

  • 31.3% of respondents had less than $500,000 on hold
  • 16.98% of respondents had between $500,000 and $999,999 on hold
  • 11.32% of respondents had between $1 million and $5 million on hold

The fact that over half (59.6%) of our survey respondents have some amount of money being held up tells us this is an area that is ripe for improvement. It is up to us, as industry experts, to identify the ways in which we’re losing money, and implement changes that will improve our organization’s revenue intake.

Additional Costs Associated with Poor Provider Data Management

There are many other areas that suffer due to poor provider data management outside of enrollment. Two worth noting are credentialing and directory maintenance.


Credentialing is the process of obtaining, verifying and assessing the qualifications of a practitioner/provider to provide care or services in or for a healthcare organization. CAQH research indicates that many organizations use multiple methods to collect the provider data required for credentialing and that moving to a single credentialing platform could reduce annual credentialing costs by 40%. On a national level, CAQH estimates that streamlining the exchange of credentialing information on one platform could save as much as $2.26 billion annually.

Directory Maintenance

Provider data collection requirements for directories are becoming increasingly more complex and require updating and confirming with greater frequency. To improve accuracy, regulators have set minimum requirements for how frequently plans must contact practices to verify and update their information.

  • CMS requires Medicare Advantage plans to contact providers quarterly.
  • States require commercial and government-funded plans to conduct outreach on a variety of schedules, including some that exceed federal requirements.

In addition to those requirements, Berkeley Research Group reports:

  • 19 states require provider directory updates at least once a month.
  • 12 states require updates between quarterly and annually.
  • 7 states require directories to be “up to date” or updated in a timely manner.

CAQH estimates providers incur annual costs of $2.65B to maintain directory records. With varying requirements across state lines at different times throughout the year, it’s no wonder the hunger for a standardized process to manage provider data is growing.

The Solution—Standardizing Provider Data Collection

There is a lot of overlap between the data sets required for credentialing, enrollment, and directory maintenance. That is why standardizing the process is a simple and effective solution that will enable the industry to save time, resources, and most importantly, money. And the journey to standardization has already begun. We believe that standardization starts with credentialing, which is why according to our shared best practices, your credentialing software should:

  • Standardize the requested content
  • Streamline the number of requests to update or submit information
  • Simplify the data submission and reconciliation requirements
  • Maintain a comprehensive database of validated data

We also believe your credentialing solution should assist with directory updates by:

  • Consolidating multiple health plan outreaches into a single outreach for each provider
  • Creating and maintaining standard roster files that can be electronically shared with Health Plans as updated or required

Everybody agrees

Standardization is the answer to reduce inefficiencies and eliminate financial waste. A 2019 AMA survey found that 67% of physicians are interested in one interface to update payors. It makes sense, providers want to spend more time with patients and less time on paperwork. With standardized data collection, providers can avoid manually updating their information with individual payors and help their patients avoid coverage issues by ensuring they are represented accurately in all payor directories.

Though managing provider data currently presents industry-wide financial implications, there are ways to address them, and that starts with standardization.