CMS Qualified Health Plan (QHP) Directory Pilot
The Centers for Medicare & Medicaid Services (CMS) launched a new provider directory pilot program with the Oklahoma Insurance Department (OID). Kate Deiters and Zach Snyder discuss the key aspects of this initiative, which aims to serve as a proof-of-concept for a centralized directory for Qualified Health Plans (QHPs) and providers, improve provider data accuracy, reduce ghost networks, and work toward a National Directory of Healthcare (NDH).
What is the Goal of the CMS QHP Directory Pilot?
CMS and the Oklahoma Insurance Department (OID) have launched the Qualified Health Plan (QHP) Directory Pilot. This program is a proof-of-concept initiative designed to evaluate the feasibility of a centralized provider directory for QHPs.
The primary goals of this pilot are to enhance the accuracy of provider data, reduce the prevalence of ghost networks, and lay the foundation for the creation of a National Directory of Healthcare (NDH). By achieving these objectives, the pilot aims to:
- Improve provider data accuracy.
- Lessen the administrative burden on providers and payers.
- Lower administrative costs.
- Support interoperable data exchange.
- Enhance patient and provider experiences.
CMS believes that this pilot will serve as a valuable proof-of-concept, guiding the future development of a centralized NDH that can effectively serve as a comprehensive database for provider information.
What Should You Be Aware of and Discussing Within Your Organization?
Health plans should closely monitor CMS’s activities related to the pilot. It is an excellent opportunity to:
- Review and understand your internal provider directory accuracy programs.
- Ensure you have the most accurate provider information available.
- Consider providing input to CMS on your experiences and any suggestions you may have, either directly or through industry trade associations.
Inside the CMS Provider Directory Pilot for QHPs
Transcript
Kate: The last item on our docket, Zach is the National Directory Pilot that CMS recently announced.
Zach: CMS did announce a National Directory Pilot, a National Provider Directory that will serve as a source of truth to ensure that health plans can use one data set to populate their provider directory that is as accurate as you can possibly get it. They issued an RFI last year announcing that they wanted to do this. However, now they’ve launched a pilot in one state in Oklahoma to see if they can pull it off in one state. If they can pull it off in one state. Perhaps they bring this idea to the rest of the country through a national provider database that will serve as a source of truth for the purposes of provider directory accuracy.
Kate: Well, we know health plans have been asking for something similar to this. Zach, what would you say is one of their ultimate goals that they’re trying to achieve with this pilot?
Zach: Well, they announced that they’re trying to achieve a greater fidelity of provider data accuracy for the entire industry. They recognize the issue of ghost networks. Senator Ron Wyden, who is the Chairman of the Senate Finance Committee, that oversees all legislation relating to Medicare Advantage and moves through his committee, Ghost Networks has been one of his major priorities. He’s proposed legislation both this year and last year and has held hearings on ghost networks and has even had the staff produce reports on ghost networks. He has announced and produced a letter and send that to CMS, saying that the efforts that CMS are undertaking with looking at this national provider directory are aligned with his goals of reducing ghost networks. So, if you look at it through the lens of one of the most prominent United States Senators, voicing support for CMS, and it’s a walk on down a path of implementing a national provider database. You could come to the conclusion that this national provider database is designed to address the issue of ghost networks as well.
Kate: Is there anything you believe our audience should be aware of or should be discussing with teams within their organization regarding this pilot?
Zach: Well, I think plan should pay attention to what CMS does here. I think it also serves as a good opportunity to bring groups of subject matter experts at your plan together to understand what your provider directory accuracy program looks like internally. How are you ensuring that you have the most accurate information available for your providers? And think about, do you want to provide input to CMS on how they’re running their pilot? You’ll have an opportunity to do that through your industry, trade associations, or on your own as a health plan with experience trying to ensure the most accurate provider data possible.
Kate: Yes, they say they love to hear from everybody, and the best way to do that is by submitting comments during their comment period. They want to know what do you think is working, what’s not working? And the comment period is a fantastic time to do that. So, we hope you all submit your thoughts and comments to them around this pilot.
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