Provider Network Verification

You already know what is wrong. The file goes out, the response file comes back, and somebody spends two days fixing records they fixed last month. The following week it happens again.

We fix the reason, not the file.

What changes

• Your team stops reworking records they already fixed
• The same records stop coming back, because they get corrected in the system that produced them instead of in the file
• Your adequacy numbers and your provider directory rest on records that actually reconcile
• The process is written down, so it stops living in one person's head

A file with no errors at all was never the target. New providers and real network changes should generate errors, and they will. What goes away is the same record coming back next Monday.

Why we can say that

We built this for a Florida Medicaid plan with a multi-region provider network. Not advised on it. Built it, ran it, and kept it running when AHCA changed the specification.

We know the PG, SL, PD and EN files. We know the difference between a Level 1 formatting reject and a Level 2 that comes back because there is no matching active Medicaid ID in the Provider Master File. We know which ones repeat, and why they repeat.

Where the errors come from

The file is assembled from whatever your systems hold the moment it gets built. At most plans that is three or four systems nobody ever reconciled to each other. Contracting holds one version of a provider, credentialing holds another, the claims system holds a third.

That produces the same handful of problems everywhere:

• The same provider entered twice under two Medicaid IDs
• One NPI showing up as both a group and a facility, because the provider is legitimately both and the systems disagree
• The same address written four different ways, so service locations multiply
• Credentialing dates that never crossed from one system to another
• Licensure that expired with nobody watching, until AHCA notices

Correcting these in the file fixes the submission. It does not fix the record. That is why next week looks like last week.

What this costs while it sits there

Your contract carries liquidated damages. Most plans never get there. The exposure is still real and it sits on a report somebody reviews.

Network adequacy is calculated from this data. If the same provider appears twice, the count says you have two. If a location multiplied because an address was written four ways, the map shows coverage you do not have. That is adequacy you cannot defend when somebody checks it.

The member directory comes from the same place. Wrong addresses, providers shown as accepting new patients who are not, phone numbers corrected in one system and nowhere else.

And it concentrates in one person. One or two people know how the file gets assembled and what each recurring error means. None of it is written down. When they leave, the weekly submission becomes an emergency.

Why this gets worse

The records nobody corrects at the source do not go away. They come back every week, and the list grows as the network grows. A plan that adds two hundred providers a year adds them to a reconciliation problem that was already there. The work to fix it is the same next year, except there is more of it and the person who understood the original process has moved on.

Who this is for

Medicaid and dental plans under AHCA contract, and the commercial plans, EPOs and workers' comp arrangements that submit provider network data to the Agency.

How we work

We work from a month of your AHCA response files, through whatever transfer method your security team uses. We trace every recurring error back to the system it came from, and look at how provider records get created, updated and reconciled across those systems.

You get a written findings document naming each error pattern and where it originates, a count of how many of your weekly rejects are the same records repeating, a remediation plan sequenced so the fixes that stop the most errors come first, and a fixed-price estimate for that remediation.

Scope covers up to one month of response files and up to four source systems. Anything beyond that is quoted separately.

If you engage us for the remediation within 90 days, the $12,500 comes off the project price.

Then the remediation. Trace, build, then run in parallel with your current process until the file goes clean on its own. Most engagements land between $60,000 and $150,000 over three to six months, depending on how many systems feed the file and how far apart they have drifted.

And once the data is clean, we can run the weekly submission for you. That is a conversation for after the remediation, not before it.

Where we are

Forward Thinkers Consulting is in Florida. Most engagements run inside your environment, on your systems, under your access controls. If you would rather it ran outside, we can host it in our own Azure tenant in a US region.