Health policy is a dynamic field, continually evolving to improve the healthcare industry. As regulators and stakeholders push for higher standards, several key trends are emerging across markets that aim to enhance the efficiency, transparency, and equity of healthcare delivery. Significant policy trends observed in various markets include a focus on provider verification timelines, data transparency, and health equity.
Key Policy Trends
Shift to Shorter Provider Verification Timelines
One of the most notable regulatory changes involves the shift from annual, semi-annual, or traditional quarterly, provider verification cycles to a rolling 90-day or shorter verification schedule. This accelerated timeline means health plans must adapt their processes and systems to verify provider information more frequently to maintain compliance and ensure data accuracy. This shift necessitates implementing efficient technologies and practices for constant data validation and provider engagement.
Accelerated Provider Data Updates
In addition to shorter verification timelines, new mandates require quicker turnaround times for updating provider information and communicating network changes. For example, we continue to see 2-day turnaround timelines to update directory information on websites and 5-day turnaround timelines to inform patients about network changes. Health plans must be agile and responsive, ensuring that any changes to provider status, network participation, or contact information are promptly reflected in their directories.
Data Transparency and Metrics
Regulators are advocating for enhanced transparency in the management of health plan data and operations. Compliance now necessitates clear and comprehensive documentation across several key areas.
Provider Outreach Activities: Data showcasing provider outreach efforts, including the frequency and methods of communication used to verify and update provider information.
Provider Data Verification Processes: Data confirming accurate provider information, ensuring they are in-network, active, and accepting new patients.
Corrective Action Plans: Documentation of corrective actions taken to address any discrepancies identified in provider data and directories.
💡 Tip: Use a comprehensive dashboard that tracks all aspects of provider data management and transparency. Regular audits should be conducted to ensure adherence to established protocols and quick identification of areas needing corrective action.
Trends: The Push for Data Transparency in Health Plans
Curious about the latest trends from state and federal regulators? Kate Deiters and Zach Snyder discuss the increasing requirements for transparency in health plan data, focusing on the importance of provider data accuracy and network adequacy reviews.
Dive Deeper with Our Full Podcast Episode! Get the full scoop on recent regulation changes and updates on network adequacy and provider directory accuracy. Listen Now
Minimizing Ghost Networks
Ghost networks—providers listed in directories but not actively treating patients—remain a pressing issue. Regulators are exploring the use of claims data to identify active versus inactive providers.
Proposed Federal Legislation
The Requiring Enhanced & Accurate Lists of (REAL) Health Providers Act, targets ghost networks in Medicare Advantage Organizations. Similarly, the Behavioral Health Network and Directory Improvement Act address ghost networks for individuals enrolled in private health insurance plans.
State Initiatives
Several states, including Illinois, Oklahoma, New Mexico, and Massachusetts, have implemented using claims data to verify provider activity, ensuring that only active providers are listed in directories.
Performance Percentages
States are increasingly adopting performance benchmarks to help health plans demonstrate improvements in data accuracy. For instance, a health plan may be required to show a 2% annual increase in data accuracy.
💡 Tip: Set internal performance benchmarks and continuously monitor progress against these goals. Use these benchmarks to drive improvements in provider data accuracy and maintain regulatory compliance.
Health Equity and Provider Characteristics
Health equity is a growing focal point in regulatory oversight. Provider verification processes and directories are now requiring data on the cultural and linguistic capabilities of providers.
How to Prepare for Industry Changes
To keep up with industry changes and stay competitive, consider these strategies:
Update Provider Data Management: Understand new regulatory requirements and update your provider data management processes accordingly.
Enhance Compliance Training: Ensure your compliance team is well-trained and knowledgeable about the latest regulations.
Audit and Modernize Tools: Evaluate your current tools and determine if they meet your needs or if you need to adopt more advanced solutions for better efficiency and accuracy.
Ensure Data Reliability: Maintain accurate, reliable, and transparent provider data to support informed decision-making.
Leverage Machine Learning: Use data-driven intelligence and machine learning to identify the right providers for your network effectively.
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