THE PROVIDER DIRECTORIES

WHAT YOU NEED TO KNOW

The Consolidated Appropriations Act of 2021 was signed on December 27, 2020. Within the bill was the No Surprises Act; Protecting patients and improving directory information accuracy. The goal is to have health plans and providers work together to improve the accuracy of provider information in public-facing directories and related materials. Providers and facilities must establish procedures to communicate changes about their provider directory information to health plans and insurers in a time frame that supports compliance. The new legislation does not pre-empt any existing state laws and generally does not apply to stand-alone dental plans. This law enacted a new mandate for self-insured group health plans and health insurance issuers that offer group or individual health insurance coverage to establish the following by January 1, 2022.

• A provider data verification process to ensure accurate provider directories.
• A response protocol for individuals inquiring about the network status of a provider.
• A database that is publicly accessible and contains accurate information about their in-network providers and facilities.

BACKGROUND: COMMON REASONS FOR INACCURATE PROVIDER DIRECTORIES

• Especially in the case of mergers & acquisitions.
• Turnover.
• Re-organization of team and personal responsibilities.

DATA MANAGEMENT AND IT INFRASTRUCTURE

CHANGE MANAGEMENT

PROVIDERS NOT HAVING AN EQUAL STAKE IN THE GAME

In the case of Medicare Advantage Plans, the responsibility of maintaining an accurate provider directory has fallen on the health plans.

COMPLIANCE REQUIREMENTS VARY

State vs state, Medicare Advantage vs Medicaid vs Commercial makes it difficult for all teams to be aligned. Organizational silos make it challenging for teams to share and update data efficiently. This is not a true representation of which providers are available at each location and accepting new patients.

• PROVIDERS LISTED AT EVERY LOCATION FOR CLAIMS PAYMENTS.
• PROVIDERS NOT PRACTICING AT THE LOCATION LISTED.
• INCORRECT PHONE NUMBERS.
• PROVIDERS NOT ACCURATELY LISTED AS ACCEPTING NEW PATIENTS.
• PROVIDERS INCORRECTLY LISTED AS IN-NETWORK.

BACKGROUND: CHALLENGES CONSUMERS FACE

Health consumers are most likely to experience trouble receiving care due to incorrect information listed in the provider directory.

NEW REQUIREMENTS: ACCURATE PROVIDER DIRECTORIES LEAD TO SUCCESS

• ACQUIRE NEW CONSUMERS.
• ENHANCE PATIENT EXPERIENCE AND OUTCOMES.
• INCREASE MEMBER RETENTION.
• POSITIVE REPUTATION GROWTH.

NEW REQUIREMENTS: TASKS TO KNOW

Plans who get it wrong are responsible for any out-of-network charges that result to the consumer. Plans need to establish a procedure for removing providers and facilities from the directory whose information cannot be verified during the specified time period. Plans must have a process in place to verify and update their provider directory information at least once every 90 days, for each provider and health care facility included in the database. Plans have two business days to update the provider directory upon receiving a provider notification that their information has changed. This includes the removal of providers who no longer are in network. Plans must indicate whether a provider or facility is in-network to consumers who inquire about that provider or facility’s network status within one business day. This information is binding.

EXAMPLE

1. A provider terminates their contract.
2. The health insurer must update their database within two business days to ensure a consumer does not schedule an appointment with that provider.
3. Suppose the updates are not made and a consumer makes an appointment with the provider who appears to be contracted with the plan due to the provider directory information.
4. In that case, the plan will be responsible for paying the out-of-network provider costs.

IMPROVE THE ACCURACY OF PROVIDER DIRECTORY INFORMATION

Providers must submit provider directory information to the health plan when they terminate a network agreement.

NEW REQUIREMENTS: PAYER AND PROVIDER RESPONSIBILITIES

NEW REQUIREMENTS: INFORMATION TO VERIFY

• Digital Contact Information
• Specialty
• Address
• Name
• Telephone Number

NEW REQUIREMENTS: BUSINESS IMPACT

QUEST ANALYTICS CASE STUDY

We worked with a client health plan to answer the question, "If I had to remove providers today who have not attested their data, what would my accessibility look like?"

• PCP Availability Decreased by 90%.
• Share of Market PCPs in Network went from 12.6% to 1.1% — A 91% Decrease.
• For Primary Care, the average distance-to-care increased from 4.2 miles to 34.3 miles.

STRATEGIES FOR SUCCESS:

CREATE A PLAN BASED ON YOUR CURRENT STATUS AND PRIORITIES

• Document and execute your compliance plan.
• Identify the people and teams who are responsible for updating your provider database and public directories. Collaborate with the teams responsible for other product lines such as Medicare Advantage or Medicaid.
• A complimentary risk assessment by Quest Analytics will help you see what's right, wrong, and missing in your provider data. Understand the entire workflow for updating your provider directory. Assess the tools and systems to ensure alignment in how you manage the provider data.

IDENTIFY CURRENT PROCESSES AND PEOPLE

• All internal and external stakeholders will need to test your procedures and document the process. Having a written Standard Operating Procedure Plan helps enhance cross-team alignment and demonstrates your efforts to regulators to comply with the new law.

STRATEGIES FOR SUCCESS: BEST PRACTICES

Here are a few proven strategies we’ve learned from working with our health plan clients:

• Review business relationships and communicate new processes.
• Implement an enterprise-wide solution to allow all teams access to the same information, at the same time (no more wait 2 weeks to hear back). By automating manual processes, you gain time, enhance team collaboration and increase productivity.

LEARN HOW UPDATES ARE COMMUNICATED

Understand how the changes to provider data are communicated to individuals responsible for the printed directories and individuals responsible for the web (online) directories. Ask your teams these additional questions:

• How do we currently handle updates?
• Is our current process successful?
• What is our current process for removing providers who no longer are in our network?
• Who is responsible for making changes to the database?
• What is our current process for making changes to the directories?
• How is the information technology (IT) team involved?

STRATEGIES FOR SUCCESS: BEST PRACTICES

• Understand the terms of agreement with your contracted providers. What is your contract structure today? Do you need to revise it to align with the new requirements? How do you ensure your network is not significantly impacted if a provider or group is terminated? How will contracting providers be evaluated in the future?