Three Reasons Accurate Member Identity Is Essential to Payer Performance and Better Care Delivery 

Updated on December 5, 2023

A recent survey of payers indicates that every key payer objective, from improved member satisfaction to increased operational efficiency, relies on a more accurate view of the correctly identified member’s medical history and needs

Incorporating a 360-degree view of members is foundational to the important work payers do today, from combatting fraud and waste, managing member data, and managing interoperability to supplying a satisfactory member experience. Having a complete view of member history and past health journeys isn’t a “nice to have” feature for payers. It is an essential, foundational capability that informs the success of all data-driven initiatives. 

Yet while 90% of payers believe accuracy of member identity is essential to operational effectiveness and efficiency, three out of four believe their current system capabilities aren’t up to the challenge.1 This is something health plans must tackle if we are to advance better care outcomes and value for all. 

The Scope of the Problem

There is consensus among payers that the industry must address gaps in their current ability to accurately identify members given the proliferation and complexity of data sources. Making the right investments in member identity solutions, such as a healthcare master data management (hMDM) system, offers a strong potential to drive numerous returns for payers, for example:

  • A better member experience and higher member engagement to improve care effectiveness. In a recent survey of payers stated that their top organizational challenges include managing high-risk members (43.3%) and effective member engagement (40%)—both of which are severely impacted and complicated by member misidentification. Yet just 10% of payers surveyed are moderately or highly satisfied with the accuracy of their existing member identity management solution. The ability to effectively engage members differentiates payer performance in today’s competitive healthcare environment, so identity resolution must be considered foundational in any overall strategy. 

Additionally recent regulations, such as the No Surprises Act, the Transparency in Coverage Rule, and the Interoperability and Patient Access rule, are creating requirements for payers to ensure more positive member experiences. But one of the greatest challenges associated with higher quality member experience is having an accurate and complete single source of truth for member identity.

Members cannot be regarded as a uniform audience, and payers know they can’t afford to overlook members’ unique life and health circumstances. Doing so risks payers missing critical and valuable opportunities to reduce avoidable overall utilization, utilization at an inappropriate level of care acuity and associated healthcare costs, which can also undermine efforts to improve health outcomes. For example, by leveraging a 360-degree view of patients to pinpoint high-risk members, health plans can connect these members with preventative or lower acuity of care in the right setting. 

  • Stronger population health management under value-based care. Ninety percent of payers agree that in their adoption of value-based care, accurate member identity is either “extremely important” (50%) or “somewhat important” (40%), according to the survey. 

To support clinically effective and cost-effective value-based care, payers must have a more granular visibility into their broader member population, and better insight into individual members within their network. With more comprehensive member data, payers can better collaborate with providers to avoid the one-size-fits-all approach and offer personalized care to better support patients and address healthcare inequities.

Critically, payers need accurate non-clinical data such as demographic and social determinants of health (SDOH) data. Social determinants—environmental and/or socioeconomic factors and health-related behaviors—account for up to 80% of outcomes. Plans can leverage hMDM systems to ensure that often-fragmented data is effectively integrated and correctly attributed to each member,  while also revealing important usage patterns or commonalities in their network. For specific populations and members that have elevated risk of avoidable, inappropriate acuity level or unnecessary utilization, payers can target tailored risk identification and preventive care outreach and guidance efforts that can lead to better outcomes and safer care. 

  • Streamlined data exchange and interoperability. According to Gartner’s 2023 Payer Interoperability Benchmarking Survey, almost 60% of payers that have invested in interoperability have not realized a positive ROI. Incomplete member records are endemic, largely due to failures to achieve identity interoperability between healthcare organizations. Seventy-three percent of payers surveyed do not believe they have complete information on their members, yet 40% did not know if their plan had an enterprise master patient index (EMPI) or master data management (MDM) solution, and only a minority (36.7%) reported that their organization did. Two-thirds understood that higher accuracy in patient-member identity would improve care management initiatives, operational efficiency and member experience.

Payers must increasingly share real-time member data internally and externally, and thus face a growing urgency to aggregate fragmented member data. The Trusted Exchange Framework and Common Agreement (TEFCA) is also driving urgency to deliver more complete and accurate member identification throughout the healthcare ecosystem. TEFCA advances principles and benefits embodied in the 21st Century Cures Act that seeks to establish a secure technical infrastructure for healthcare networks—but few organizations are prepared and ready to meet its requirements today. Both payers and providers need improved capabilities to ensure that the data they must now share is both comprehensive and accurate.  

A Way Forward

The stakes for member identity accuracy and management are high, and success comes down to the ability to identify—with certainty—who is who in an environment where data streams are multiplying and identity interoperability is an imperative. Therefore implementation of a healthcare master data management (hMDM) system is becoming critical in enabling payers to have a valuable and high impact role in effectively managing their members’ healthcare, beyond merely paying claims and providing guidance on appropriate care delivery. Complete and accurate member data is critical to advancing clinical and cost-effectiveness, and to truly making a meaningful difference in members’ lives, care experience and health outcomes. 

1Gellert G.A., Erwich M.E. and Krivicky-Herdman S., The importance of accurate member identity in the performance of payer organizations. The Journal of Hospital Administration 2023;12:1-12. DOI: 10.5430/jha.v12n2p11.

George Gellert 1
George Gellert

George A. Gellert, MD, MPH, MPA, FABPM is a physician, former health system CMIO and epidemiologist focused on using health information technology to improve population and public health outcomes through transformative technology, organizational strategy and services. Dr. Gellert is also a clinical advisor to Verato.