Evolent Health Services

CASE STUDY Matchmaker, Matchmaker: Making the Provider Data Match Evolent Health Services drives a dramatic turnaround in provider data accuracy for a partner health plan. 67.3% of TINs could not be matched between rosters and contracts THE CHALLENGE From administering clean payments to helping members find in-network physicians, accurate provider data is the linchpin of a well-run health plan. When this data is flawed or incomplete, it sets the stage for disgruntled providers and frustrated members, as well as administrative waste. In late 2020, Evolent worked with a plan that had previously made network acquisitions, amplifying the already challenging ability to have clean provider data. The plan's provider rosters did not line up with its list of who they deemed in network, nor did the rosters line up with the respective provider reimbursement contracts. For example, across more than 3,900 provider practices, under a third (32.7%) could be matched by Tax Identification Number (TIN) when looking across provider contracts and the respective roster of in-network providers. Match rates at the more granular level required for claims processing, which requires data such as National Provider Identifier (NPI1) and location of service, were even lower. EVOLENT'S APPROACH Evolent worked with its health plan partner to create a single source of truth for provider data. Together, we crafted a thoughtful, comprehensive and systematic strategy for tackling data issues that built on various milestones over several months to approach 100% accurate matching. Establishing a Source of Truth Across Roster and Reimbursement Data Evolent worked closely with the health plan to establish a list of all contracted providers and ensure we had corresponding reimbursement data. Through this work, we reviewed approximately 4,000 contracts for providers. As a part of this effort, we uncovered another 1,100 providers without associated claims over the previous 12 months. We then collaborated with the health plan to determine the network status of providers without claims and those with missing contracts and update the providers' records.

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