Are enrollees receiving the healthcare services they were promised? Inaccurate provider directories and ghost networks have been longstanding concerns in the healthcare industry, particularly with mental health services. Recognizing the need for improvement, lawmakers have introduced new legislation to address inaccurate data and help seniors receive the care they purchased. The Requiring Enhanced & Accurate Lists of Health Providers Act, also known as the REAL Health Providers Act, aims to prevent ghost networks by imposing additional requirements on Medicare Advantage (MA) plans to maintain accurate provider directories.
Current Provider Directory Accuracy Requirements
To better understand the proposed legislation, let’s first review the current regulations governing provider directory accuracy for MA organizations. According to existing law, MA organizations must maintain clear, accurate, and standardized information about their provider network in their online and printed directories. The Centers for Medicare & Medicaid Services (CMS) requires MA organizations to provide plan directories to enrollees by October 15th each year, within 10 days of enrollment, and upon request by an enrollee throughout the year.
Additionally, MA organizations must include printable and searchable provider directories on their websites. Additionally, they must maintain a publicly accessible Application Programming Interface (API) that adheres to industry standards, offering a complete and accurate directory of the MA plan’s contracted provider network.
In order to keep the directories up-to-date, MA organizations must contact contracted providers quarterly to verify and update at a minimum the following directory information:
- Provider Name
- Provider Specialty
- Whether or Not the Provider Accepts New Patients
- Practice Address
- Phone Number
- Provider Offers Telehealth Services
- Provider Cultural and Linguistic Capabilities, Including Languages and American Sign Language
Directories must be updated within 30 calendar days after the MA organization receives verification or updates about provider directory information.
TIP: Read our policy brief to learn more about the current provider directory requirements.
Proposed Provisions of the REAL Health Providers Act
Now, let’s get into what the REAL Health Providers Act proposes as key changes to the existing rules governing provider directories in MA plans.
Mandatory Verification and Removal of Providers
Starting in plan year (PY) 2026, network-based MA plans would be required to do the following:
1. More Frequent Outreach, Verification, and Updates: MA plans must verify provider directory information at least every 90 days. This aligns with the No Surprises Act, which emphasizes ongoing outreach instead of quarterly updates.
2. Indication of Unverified Providers in the Directory: MA plans must clearly note in their directories which providers have unverified information.
3. Prompt Removal of Providers: When the MA plan determines a provider is no longer part of the network, they must remove that provider from the online and printed directory listings within five business days.
Cost-Sharing Protection for Enrollees
Provider directories would be required to include all the information enrollees would need to access covered benefits from a contracted provider. If an enrollee receives services from an out-of-network provider who was listed as in-network in the plan’s directory when the appointment was made, the MA organization would be required to cover the out-of-network care, as long as it was a covered item or service. The enrollee would only be responsible for in-network cost sharing.
Annual Provider Directory Accuracy Reports
MA contracted plans would be required to conduct and submit annual reports of their provider directory accuracy to the Department of Health and Human Services (HHS) Secretary starting in PY2026. The report would include information about provider specialties with high inaccuracy rates as determined by the HHS Secretary for each plan.
Publication of Provider Directory Accuracy Scores
Beginning in PY2027, the HHS Secretary would be required to publish provider directory accuracy scores on the CMS website in a machine-readable format. Additionally, MA plans would need to post their accuracy scores on their directory.
Hospital and Facility Verification
While the REAL Health Providers Act requires provider information to be verified every 90 days, the HHS Secretary may allow plans to verify hospital and other facility information less frequently, as long as annual verification is ensured.
What's Next? Legislative Status and Future Updates
Advancement through the Better Mental Health Care, Lower-Cost Drugs, and Extenders Act
On November 8, 2023, the REAL Health Providers Act was passed by the Senate Finance Committee as part of the Better Mental Health Care, Lower-Cost Drugs, and Extenders Act. The chairman’s markup is available here. We will keep you updated on any developments as it moves through the legislative process.
Accurate Directories, No Ghosts
Stay ahead of the changes brought by the Requiring Enhanced & Accurate Lists of Health Providers Act with Quest Enterprise Services™. Our solution empowers Medicare Advantage Organizations to streamline provider verification, identify data changes, and meet expanding regulatory requirements. Contact us today to discover how our proven solutions can simplify your organization’s compliance efforts and navigate this dynamic landscape with confidence.
Proven Solutions for Your Provider Network Management
Looking to simplify your workload? Let Quest Analytics take on the heavy lifting! Our solutions and dedicated team specialize in provider data accuracy and provider network adequacy for various lines of businesses, including Medicare Advantage, Medicaid and Commercial. Schedule a strategy session today and see how we can help you every step of the way.