Concerned about widespread inaccuracies in network directories for health plans, lawmakers across the country are seeking stricter data collection requirements. A mix of new state and federal regulations require payers to provide consumers with up-to-date network directories of available healthcare professionals. This year alone, state legislation regarding the accuracy of network directories has been introduced in Connecticut, Georgia, Hawaii, Illinois, Massachusetts, Maine and Texas. California enacted a provider directory law last year.
The concerns are real. According to CMS, close to half (45%) of Medicare Advantage online provider directories are inaccurate. Plans that fail to keep their directories updated face steep fines — up to $25,000 per error per physician and up to $100 per physician for errors in plans sold on HealthCare.gov.
Failure to keep directories current can cause all sorts of problems. Without accurate information, patients risk choosing a doctor who is out-of-network and not fully covered by their health plan. They may not know that the physician isn’t accepting new patients or Medicare patients, or that the office has moved to a new location.
This has contributed to the problem of “surprise” medical bills, invoices patients receive with unanticipated costs because the care was inadvertently provided outside their insurance carrier’s network. A recent study by the Commonwealth Fund found that only six states have laws that protect consumers from balance billing for out-of-network care delivered in emergency departments or in-network hospitals, and even those laws have loopholes.
Surprise bills are a major symptom of poor data accuracy, says Tom Suk, senior director of provider data solutions at LexisNexis, which developed a product to streamline directory management. “It’s a major reason why CMS is really clamping down.”
The other concern, says Laurie McGraw, SVP for health solutions at the American Medical Association (AMA), is that patients will fail to follow through on a treatment plan if they realize they’ve received care out-of-network.
Swamped by update requests
As health plans respond to these mandates, physician offices are inundated with repetitive data verification requests from health plans required to constantly verify the quality of network directories. According to the AMA, the average doctor is affiliated with 12 health plans and will undergo a rigorous data audit for each of them.
Provider groups agree that consumers need accurate information on which to base their healthcare decisions, but argue the current system of data collection is fragmented, duplicative and wasteful, contributing to a staggering $361 billion in healthcare administration costs annually in the U.S.
“It’s problematic for both sides,” says Robert Tennant, director of health IT policy at the Medical Group Management Association (MGMA). Plans need to ensure there is sufficient network access for their customers, but at the same time physicians struggle to keep up with multiple requests. “It could be multiple products from different health plans … or multiple forms for various healthcare products offered” by the same insurer, he tells Healthcare Dive. “I’ve talked to folks and they’ll say they could spend all day long filling out these forms.”
For example, not only are laws requiring plans to verify data such as name, location, telephone number and whether a doctor accepts new patients but some, such as California’s, require directories to include a doctor’s proximity to public transportation, including for people with disabilities.
Simplifying the process
So how is the industry coping with this? Where there’s a problem there will be folks trying to solve it, and network directories is no exception. Several organizations, including LexisNexis, have developed software tools that simplify the process of reporting and updating provider data.
LexisNexis began working with AMA two years ago to improve the accuracy of network directories while reducing office disruption. The result, Verify HCP, allows physicians to prefill, collect, monitor, cleanse and update data in real-time. It also includes a multichannel outreach campaign to meet the different federal and state regulatory guidelines.
Launched 10 months ago, Verify HCP currently maintains over 2 million provider types and facilities.
The Council for Affordable Quality Healthcare (CAQH) has a provider directory maintenance tool. Called Direct Assure, it works in concert with CAQH’s ProView credentialing database to allow providers to review and update self-reported data for use in network directories. The database includes more than 1.3 million providers.
Payers are also looking at the issue. Last year, America’s Health Insurance Plans (AHIP) worked with two vendors — Availity and BetterDoctor — to contact over 160,000 providers, testing different ways to coordinate with them to update directory information. An independent evaluation identified three main opportunities for improvement: improving provider accountability via contractual requirements and other incentives; developing an industry-wide set of standards for directory data definitions, file format protocols and other validation requirements; and improving provider engagement.
“Health plans recognize that maintaining accurate provider directories is a shared responsibility,” Cathryn Donaldson, director of communications at AHIP, told Healthcare Dive.
While competition could hamper the goal of one-stop shopping, where a provider would enter his or her professional information one time, current efforts to streamline directory reporting are promising. The question remains, however, whether government insurance programs will participate in these solutions.
Medicare continues to require providers to follow its own credentialing system, PECOS, despite a high level of overlap with the industry’s ProView system, notes Tennant. The agency’s argument is the same health plans used when they previously didn’t want to join forces — that CMS’ needs are different from other health plans. “The answer, of course, is you’re not,” he says.
In a yet-to-be-published MGMA survey, 94% of respondents said they favored a single credentialing source for Medicare, Medicaid and commercial payers. Tennant believes the same would be true for directories. “Anytime you can harmonize these data capture requirements, it’s always better for the physician practices,” he says.