The healthcare payer organization, serving four million members, faced challenges with their complex and fragmented provider data repository, which lacked scalability and accuracy. Compliance with mandates from the Centers for Medicare and Medicaid Services (CMS) related to provider directory accuracy was also a pressing concern. The organization needed a comprehensive program to create a simpler, scalable, and compliant provider data repository.
As the program leads, we established clear program objectives, developed a governance model, and provided oversight to a team of project managers to execute the multi-year program with eight enterprise projects and a combined cost of $10 million.
The solution involved consolidating data from various internal and external sources, standardizing data formats, and implementing data validation and cleansing processes for accuracy and consistency. A scalable technology infrastructure was also developed, including a robust data management system and automated data feeds from external sources to keep the repository up-to-date.
To comply with CMS mandates, rigorous data validation processes and regular data audits were implemented. A communication plan was developed to engage providers in the data validation process and keep them informed about the importance of accurate data in the provider directory.
A governance model was established with regular progress reviews, risk management, and issue resolution processes. Support and guidance were provided to project managers to ensure alignment and coordination among projects. Communication and collaboration with cross-functional teams were emphasized for success.
The successful implementation of the healthcare payer organization’s provider directory program resulted in several positive outcomes. The new provider data repository was simpler, more scalable, and compliant with CMS mandates. Data consolidation, validation, and standardization improved accuracy and consistency, resulting in enhanced provider directory accuracy and member satisfaction.
Significant cost savings were achieved through streamlined data management processes and automation of data feeds. The robust technology infrastructure ensured sustainability and scalability for future updates and changes.
The governance model and oversight led to on-time and on-budget delivery of the program. The successful completion of the program earned recognition from senior leadership and stakeholders, positioning the healthcare payer organization as a leader in provider directory accuracy and compliance.
