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PD03 – Provider Data: What is Known and What is Assumed? | Mark Martin – Availity

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PD03 – Provider Data: What is Known and What is Assumed? | Mark Martin – Availity

PD03 – Provider Data: What is Known and What is Assumed? | Mark Martin – Availity

There are two kinds of Provider Data

Explicit provider data comes directly from the providers, their groups or even their IT systems (i.e. EMR, RCM, etc). Since this data is coming from the source, it’s assumed to be up-to-date and accurate. However, as we learned in episode 11 (PD-02) there are subtleties and complexities to consider. For example, there are scenarios where it’s best to go straight to the provider and others where you must talk to the group instead. You see, there are contractual complexities that change the context of the information. The context of the data is as important as the data itself.

Implicit provider data comes from secondary activities that involve the provider. For example, we can use claims data to make certain assumptions. You should be able to look at claims data and see what facilities they work in. If they submit a claim for a procedure done at facility X, then they should be listed at facility X on our provider directory. Right? Riiiiight???? Not so fast! That provider was covering for her colleague who was away at a medical conference and may never work in that office again. She certainly won’t be accepting any new patients there. If you add her to that location in your directory and later CMS tries to verify she works there… DING! That’ll be $25K. Thank you. Come again! I’m being a bit dramatic to make my point, but once again, we need context.

On this episode (part 3 in our ongoing provider directory series), Mark Martin, Director, Payer and Vendor Portfolio at Availity, tells us about the gap between what is known (explicit provider data) and what is assumed (implicit provider data) and the difficulty that lies between. It’s a fascinating discussion that addresses this gap, and so much more. I hope you enjoy it!

– Don Lee

Prefer to read it? Transcription coming soon!

About Mark Martin and Availity

Mark Martin (@HIT_MMartin) is Director, Payer and Vendor Portfolio at Availity.

As an industry-leading, HITRUST-certified health care information technology company, Availity serves an extensive network of health plans, providers, and technology partners nationwide through a suite of dynamic products built on a powerful, intelligent platform. Availity integrates and manages the clinical, administrative, and financial data needed to fuel real-time coordination between providers, health plans, and patients in a growing value-based care environment. Facilitating over 8 million transactions daily, Availity’s ability to provide accurate, timely, and relevant information is vital to the financial success of its clients. For more information, including an online demonstration, please visit

Mentioned on the Show

Lessons Learned from AHIP’s Provider Directory Pilot Programs – Summary blog post

Provider Directory Pilot Program Overview and FAQ – w/ link to Full White Paper

5 Reasons Accurate Directory Information Helps Providers by Mark Martin

Inaccurate provider directories create barriers to care by Mark Martin, Dianne Wagner

About the Provider Directory Podcast Series

This episode is part of our ongoing Provider Directory series that aims to dissect the issue from all perspectives, including provider, payer, patient, and regulator. Our goal is to help facilitate an expanded national conversation that drives us towards an open, collaborative industry solution.

Check out all our Provider Directory posts and episodes here!

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