Addressing the Complexity of Provider Information in Claims Data
As part of the comprehensive support that we provide to our clients and data users, Onpoint hosts a quarterly webinar, “Onpointers – Data Insights,” that gives attendees an in-depth look at a relevant topic within the world of healthcare claims data.
In response to client interest, this month’s installment focused on how Onpoint is addressing the complex challenge of parsing provider data from healthcare claims, enabling agencies and researchers to more confidently track cost, quality, and utilization at the provider level.
The challenge is considerable. The often-byzantine connections between individual providers, provider organizations, and large healthcare systems – which change frequently and at a more rapid pace than existing solutions can capture – make accurate tracking difficult. Claims data, with its gaps and inconsistencies, further compounds this issue. To tackle these challenges, Onpoint offers two key solutions: the Provider Index Table and Provider Directory.
Provider Index Table
The Provider Index Table draws upon the National Plan and Provider Enumeration System (NPPES) maintained by the U.S. Centers for Medicare and Medicaid Services (CMS) to validate the provider data received in submissions from commercial health plans and public payers by all-payer-claims databases (APCDs) and other healthcare-related data collection initiatives.
This comprehensive index resolves discrepancies in provider information across claims by assigning unique internal provider IDs and linking providers with accurate demographic and organizational data essential for analytics.
Provider Directory
While the Provider Index Table helps our clients and analysts perform analyses using the imperfect provider data in healthcare claims, it can’t solve the larger structural issues that make it difficult to keep provider rosters current or provide information about the fluid, overlapping relationships between providers and larger entities or facilities.
To help mitigate these issues, Onpoint has created a dynamic, web-based portal that enables users to explore and manage affiliations between providers and organizations. By combining validated provider data from claims with authoritative external data sources – including NPPES and other federal databases as well as client-supplied rosters – and leveraging Onpoint’s trusted attribution methods, the Provider Directory ensures superior linkage, accuracy, and usability compared to existing approaches.
In addition to bringing together these previously siloed data sources, the Provider Directory also enables credentialed users to update and maintain relationships between providers and organizations prior to performance reporting. This helps create a more robust and accurate picture of the healthcare landscape in a state or region and allows provider information to be updated as needed, rather than when changes are reflected in claims data or external databases.
Onpoint’s Provider Directory includes rosters of both providers and organizations, and users can see the relationships between providers, provider organizations, and larger medical groups. The data includes affiliation dates, so users can easily track an individual provider over time and across different organizations.
During the webinar, Analytics Engineering Manager Janelle Fredericks walked users through a few real-world examples of how the data in the Provider Directory can be leveraged for analysis. Using the Provider Directory alongside some of Onpoint’s existing data enhancements, she demonstrated how the users can determine what providers and organizations provide services via telehealth and how the median price for a given service varies across organizations.
Learn more
Interested in learning more about Onpoint’s provider solutions? Contact us at information@onpointhealthdata.org.
The next installment of “Onpointers – Data Insights” – an exclusive resource for Onpoint clients and data users – will take place in March 2025. You may view all previous sessions on the Resources page of our website.