Quest Analytics NDH RFI Comments.pdf

December 6, 2022

The Honorable Chiquita Brooks-LaSure
Administrator
Centers for Medicare and Medicaid Services
Hubert H. Humphrey Building
200 Independence Avenue, SW, Room 445-G
Washington, D.C. 20201

RE: CMS-0058-NC; Request for Information on establishing a National Directory of Healthcare Providers & Services.

Dear Administrator Brooks-LaSure,

Thank you for the opportunity to respond to your Request for Information (RFI) seeking comments on establishing a National Directory of Healthcare Providers & Services (NDH) that could serve as a centralized data hub for healthcare provider, facility, and entity directory information nationwide. We applaud the goal of this RFI to gather insight about ways to improve the availability of accurate provider data to help patients find providers, facilitate interoperable provider data exchange, and help payers improve the accuracy of their provider directories through the NDH.

Quest Analytics views the development of the NDH as a needed resource to improve accessibility to health care for consumers. We recognize this is a long-term effort that will be most effectively implemented in planned phases over several years. While the RFI invites responses to a multitude of questions, we focused on answering questions related to the intersection of provider data integrity in health plan provider directories, health plan provider network performance, and compliance.

Provider network adequacy depends on accurate provider data. Instances of inaccurate information leading to access constraints for consumers have been widely reported in Medicare Advantage provider networks as well as in other lines of business. Provider network directories are known to include providers who are listed as in-network but are not available to patients due to a variety of factors, including incorrect provider contact or location information, lacking capacity to accept new patients, and incorrect specialty designations.

Accurate provider data is central to maintaining true network adequacy for consumers. When provider data is incorrect, and therefore the provider is not an accessible point of care for a consumer, network adequacy standards met through a contracted provider network are overstated. This overstatement is due to the inclusion of providers in network files used for network certification who are not able to be accessed by patients.

For the NDH to fully support provider network adequacy compliance, we recommend CMS research and adopt established policies or processes that could raise the likelihood of success. Among these policies would be a requirement placed on health plans to proactively, on a regular basis, reach out to providers to confirm the accuracy of their provider data like the requirements established in the No Surprises Act (NSA). Another best practice to consider is a requirement for providers and facilities to proactively, on a regular basis, update their data in the NDH.

Having worked in similar industry-level endeavors over our multiple decades in provider network management, we suggest four primary pillars to guide the success of the NDH:

Our response is organized in a question-and-answer format, where we are directly responsive to the pertinent questions posed in the RFI.

About Quest Analytics

Quest Analytics is a network management technology company with a long history in developing and measuring adequacy standards and network data integrity. One of our key focus areas is the development of provider data integrity tools to measure, manage, and monitor the accuracy of directories and their relationship to network adequacy. We work with 90% of health plans in America. Across that community are multiple lines of business, including Medicare Advantage, Medicaid, Exchange, Commercial, and Self-Funded products, and coverage types, including medical, dental, vision, and other specialties. In addition, Quest Analytics technology and expertise are leveraged across CMS in Medicare Advantage and QHP and with more than 20 state regulators overseeing Medicaid and Commercial products. We are committed to evidence-based, fair, and equitable network adequacy standards that continually improve health outcomes for patients.

Benefits and Challenges

You asked commenters to address what benefits and challenges might arise while integrating data from CMS systems into the NDH. You would like to know what data elements from each system would be important to include in the NDH versus only being available directly from the system in question.

We believe the primary benefit of integration is the introduction of a single dataset through the creation of the NDH. The NDH represents a significant step toward building a trusted resource for provider data.

Combining data sets designed for purposes other than verifying provider data accuracy will present a challenge. Each of these databases is designed to support a different need (NPI registration, claims adjudication, Member engagement, etc.). Therefore, logic will need to be built to resolve conflicts among the datasets to determine which data elements to include in the new NDH. Once data elements are identified, CMS will need to demonstrate the resulting NDH is better than data currently maintained by issuers over time, as information changes regularly.

Regarding the optimal number of data elements from existing CMS systems to include, more accurate data is always better for the consumer. The more elements included and verified in the NDH, the more useful the NDH becomes to a broader audience. While most accuracy improvement projects focus on traditional consumer-facing elements (name, address, phone, specialty, office hours, etc.), the value of the NDH increases exponentially with elements that inform decision-making for consumers, such as group affiliations, accepting new patients, hospital affiliations, digital contact information, gender, languages spoken, ethnicity, race, line of business participation, and other provider characteristics.

Similar Federal Systems

You asked if there are other CMS or federal systems with which the NDH could or should interface to exchange directory data. You asked what these systems are, how the NDH should interact with these systems, and for what purpose. In addition, you asked about data elements from each of these systems that would be important to include in the NDH.

There are other federal systems that should be included, and we believe many of these would allow for the expansion of the ability to measure health equity adequacy and access and therefore make the NDH increasingly valuable. Resources that capture race and ethnicity, cultural competency, access to public transit, gender, and quality are sources to consider.

The goals of the NDH should be to create a comprehensive and inclusive dataset, not limited to traditional provider and facility types. If the broad array of providers beyond physicians and facilities is excluded, the result will be the creation and maintenance of multiple sources. Each source will have to be maintained separately. That will increase the administrative burden and reduce the value of the NDH. A phased approach to include different provider types over time is an option to allow for prioritization and demonstrate to the industry that the goal will be broader and expand over time.

Local Integration

You asked if there are systems at the state or local level that would benefit the NDH to interact with, such as those for licensing, credentialing, Medicaid provider enrollment, emergency response, or public health.

We believe several state-wide databases can contribute to the NDH and agree with those mentioned in the RFI, such as state licensing sources and Medicaid enrollment, along with state-based verified data. The inclusion of state-based datasets may lead to broader adoption of the NDH and ultimately reduce the administrative burden for providers and health plans participating in federal and state health coverage programs.

Types of Data

You asked what types of data should be publicly accessible from the NDH and what types of data would be helpful for CMS to collect for only internal use (such as for program integrity purposes or provider privacy).

As stated earlier, the more publicly accessible data the NDH can provide, the more valuable and adoptable the NDH becomes to a broader audience. Having a roadmap to illustrate the establishment, and long-term evolution, of the NDH, is about more than simply improving provider directory accuracy. Including data essential for consumers to make informed decisions about their health care will increase the value of the NDH. That will require data related to Social Determinants of Health and Health Equity, leveraging data to identify provider deserts and reduce the instances of ghost networks resulting from inaccurate data.

Health Equity

You stated that you want the NDH to support health equity goals throughout the healthcare system. You asked what listed entities, data elements, or NDH functionalities would help underserved populations receive healthcare services. You asked what considerations would be relevant to address equity issues during the planning, development, or implementation of the NDH.

We believe there are provider characteristics that should be collected and shared that will allow for the development of new health equity network requirements and support the measurement, management, and monitoring of a provider network to assure that the health equity needs of the population are aligned to the provider characteristics and can be measured to illustrate the equity of the network. Some provider characteristics related to health equity include gender, languages, ethnicity, race, cultural competency, distance from public transit, and standardized quality performance ratings, such as MIPS and facility Star Ratings.

Targeted Outcomes

You asked how CMS could evaluate whether the NDH achieves the targeted outcomes for its end users (for example, that it saves providers’ time or that it simplifies patients’ ability to find care).

We are confident that CMS could build targeted measures to determine the success of the NDH. Some examples include measuring the reduction in administrative burden currently experienced by providers who, today, must respond to multiple requests for data updates driven by health plans and regulators, measuring consumer satisfaction related to finding an appropriate in-network provider, and tracking provider participation and attestation in the NDH over time.

In a GAO report entitled, Actions Needed to Enhance CMS Oversight of Provider Network Adequacy, GAO indicated that CMS does little to assess the accuracy of the network data in applications Medicare Advantage plans submit for review to CMS, even though the submissions contain the same data elements as in provider directories, which have been shown to be inaccurate in a number of government and private studies. Ensuring the NDH has data verified by both health care providers and health plans will go a long way to help CMS improve its ability to measure and monitor the accuracy of provider directories for network adequacy purposes in Medicare Advantage and other health care programs.

Provider Types

You asked if the NDH should include allied health professionals, post-acute care providers, dentists, emergency medical services, nurse practitioners, physician assistants, certified nurse midwives, providers of dental, vision, and hearing care, behavioral health providers (psychiatrists, clinical psychologists, licensed professional counselors, licensed clinical social workers, etc.), suppliers, pharmacies, public health entities, community organizations, nursing facilities, suppliers of durable medical equipment or health information networks. You asked that commenters focus on entities that may not currently be included in CMS systems.

We believe that including more providers will aid the adoption of the NDH. We suggest positioning the NDH to accommodate the expanding role of allied health professional providers. Examples of how additional provider types may make the NDH a more valuable resource include:

  1. Nurse practitioners/Physician Assistants – there is a PCP shortage, and as a result, many states are allowing NPs and PAs to serve in a primary care capacity. Without including these provider types, an expanding number of access points will not be considered in the database.
  2. Behavioral Health – there is growing pressure on parity in mental and physical health access. Health systems and issuers are responding by increasing the utilization of clinical professionals such as counselors and licensed clinical social workers. Without these provider types included in the NDH, the ability to measure mental health parity compared to medical/surgical providers will be challenged.
  3. Other provider types listed in the RFI are requirements in many state programs, and excluding them will diminish the value of the NDH to state regulators.

Access and Consumer Choice

You asked what provider or entity data elements would be helpful to include in the NDH for use cases relating to patient access and consumer choice (for example, finding providers or comparing networks).

We believe consumers need access to more information beyond name and contact information to ensure they can choose providers that align with their gender preference, languages spoken, race, ethnicity, ADA accessibility, and to identify providers who have completed cultural competency. There would be value in adding easy-to-understand indicators of quality based on outcomes, efficiency, member satisfaction, and access. A similar example is the Star Ratings system that currently helps Medicare consumers compare the quality of Medicare health and drug plans being offered, so they are empowered to make the best healthcare decisions for them.

Lines of Business

You asked if there are specific strategies, technical solutions, or policies CMS could pursue to encourage participation in the NDH by group health plans and health insurance issuers offering group or individual health insurance coverage for programs or product lines not currently under CMS’ purview.

We encourage CMS to issue guidelines around the NSA, Section 116, and to determine if, in the future, the NDH could be leveraged to comply with the regulations around enforcement of maintaining accurate directories for commercial lines of business. In the NSA, health plans and payers are required to proactively reach out to providers to verify provider data at least once every 90 days. Therefore, if CMS provided access to the NDH, and the NDH data was verified every 90 days, then the NDH could aid in monitoring network adequacy for health plans and improve compliance with the NSA requirements. In the future, the requirements of the NSA, Section 116, could be extended to include government programs.

Data Collection Burden

You asked how data can be collected, updated, verified, and maintained without creating or increasing the burden on providers and others who could contribute data to the NDH, especially for under-resourced or understaffed facilities.

We encourage CMS to create a portal whereby this information can be verified directly by the provider or the provider’s third-party agent. Additionally, we encourage CMS to collaborate with other organizations that have verified provider data within their systems that could serve as a contributor to the NDH.

Update Frequency

You asked about current and potential best practices regarding the frequency of directory data updates.

We encourage CMS to require providers to update information based on the expected frequency of changes for various data elements. For information that is not likely to change, such as cultural competency, ADA accessibility, race, and ethnicity, verifying once or less frequently is sufficient. More dynamic data, such as an address, specialty, phone, and access to public transit, may be updated quarterly to maintain a high degree of accuracy. In addition, to protect consumers, health plans should have a shared responsibility to verify the information specific to their contractual arrangement with network providers (accepting network coverage, accepting new patients, appointment wait times, etc.). In all cases, data should be verified in a manner consistent with laws and rules related to provider data accuracy, such as the NSA.

Technical Solutions

You asked about specific strategies, technical solutions, or policies CMS could implement to facilitate timely and accurate directory data updates and how NDH data submissions could be incentivized within the healthcare industry.

We believe the NDH could be used as part of the network adequacy review process. For example, requiring providers included in the network files reviewed for certification by CMS also be included in the NDH in order to satisfy the network adequacy review requirements would provide insight into actual access for consumers.

Data Intermediaries

You asked if there are existing entities that would be helpful to serve as intermediaries for bulk data verification and upload or submission to the NDH and existing models that demonstrate how this can be done.

We encourage CMS to look for business collaborators to improve the value of the NDH with their industry expertise in data verification. Forming an association of business entities to participate in the process will increase the speed-to-market aspect needed to maintain market momentum.

Conclusion

Thank you for taking the time to consider our response to CMS-0058-NC; Request for Information on establishing a National Directory of Healthcare Providers & Services. If you have any questions or comments, please feel free to reach me via email at zach.snyder@questanalytics.com or call (206) 427-3895.

Sincerely,

Zach Snyder
VP Government Relations
Quest Analytics