Gather around healthcare enthusiasts! The focus on accurate provider data is heating up and we have the inside scoop. From federal and state regulations to health policymakers, the buzz is gaining momentum. Keep reading to stay in the know.
Current Activity to Ensure Accurate Provider Data
What Provider Data Accuracy Rules are in place?
Let’s start by taking a quick moment to go over the current regulations. Trust us, this is important. Watch the video below and let our expert Scott Westover, SVP of Network and Regulatory Strategy, fill you in on the latest provider data accuracy rules across all markets.
The Growing Need for Accurate Provider Data: A Closer Look
Now let’s look at what’s new.
Regulations Prioritize Accurate Provider Data
Accurate provider data is crucial to providing high-quality healthcare services. As you know, you heavily rely on this information, and any errors can have significant consequences for both healthcare consumers and insurers. Delayed treatments, billing issues, and limited access to healthcare are just a few of the potential repercussions of inaccurate provider data.
As a result, policymakers and regulators are taking steps to improve data accuracy. This ranges from introducing new legislation to strengthening oversight and increasing penalties for noncompliance. These efforts demonstrate a commitment to providing reliable healthcare services and minimizing the harm caused by inaccuracies. Below, we highlight recent developments in this ongoing quest for accurate provider data.
Recent Activity Supports the Increasing Focus on Accurate Provider Data
CMS Provider Directory Oversight and Compliance for Medicare Advantage Organizations
Let’s start with the latest news from one of the main drivers, the Centers for Medicare & Medicaid Services (CMS). In the Final 2024 Medicare Advantage rule, CMS stated they intend to monitor health plan compliance with the proposed new requirements through:
- Periodic Online Provider Directory Reviews
- As CMS deems necessary
- Other activities consistent with CMS’ existing compliance monitoring regarding provider directory requirements
Members of Congress Support Oversight
Ron Wyden, Oregon Senator and Chairman of the Finance Committee, is calling for action by urging CMS to keep a closer eye on provider directories. In February 2023, Senator Wyden sent an open letter to CMS encouraging them to increase provider directory oversight.“I strongly urge CMS to build on the proposed changes to include oversight of provider directory accuracy, such as by examining accuracy through regular audits or publicly posting provider directories as machine-readable files on the CMS website.”1 Senator Wyden and other members of Congress believe this is a crucial step in holding insurance companies accountable for the provider networks they offer. In addition, patients receive the care they deserve.
Recent Actions from Insurance and Medicaid Agencies
Georgia Insurance Commissioner issues the largest fine in department history.
The Georgia Insurance Commissioner sent a message by issuing the largest fine in the department’s history. The reason behind the hefty penalty? A collection of deficient practices, with one glaring issue being an ongoing pattern of inaccuracies in the provider directories.
The Illinois Department of Insurance establishes new enforcement rules for the Network Adequacy and Transparency Act (NAT Act).
Big changes are happening in Illinois’ health insurance scene! The Illinois Department of Insurance has been dishing out fines – one, in particular, was due to a health plan’s failure to properly alert regulators about a significant change in their provider network. The recurrence of violations prompted the Joint Commission on Administrative Rules to pass new rules for how the Department of Insurance will enforce the Network Adequacy and Transparency Act (NAT Act).
Florida Medicaid fines 11 Managed Care Organizations.
Things got pretty heated for Florida Medicaid as 11 of the state’s Managed Care Organizations (MCOs) – including three managed dental care companies – were served monetary fines. The allegations? Everything from inaccurate reporting of network adequacy to failing to disclose critical network information to the state in a timely manner. Even though this occurred over a year ago, it’s still an unforgettable event that deserves to be noted.
Arizona Medicaid Fines Providers
Arizona’s Medicaid agency, the AHCCCS, is taking a strong stand against providers who aren’t upholding their responsibilities. After alerting providers to revalidate their status in the AHCCCS Provider Enrollment Portal last November, a staggering 92% failed to take the necessary action. Therefore, the 8% or 5,288 providers who did not are targeted for termination.
AHCCC’s move reflects increased efforts by regulators and policymakers to hold providers accountable for accurate network data, not just the health plan.
Future Provider Data Accuracy and Network Adequacy Rules
Coming Health Policy Changes to Strengthen Provider Network Oversight
Overall, it’s clear that the focus on provider data accuracy will only grow as we move forward. With many legislative sessions in progress, we expect updates on federal and state laws. Rest assured that we’ll keep you informed as we learn more. Stay tuned!
Process, protocols and procedures for accurate Provider Data
Get Your Provider Data Ready for Prime Time with Quest Analytics
Given this increased scrutiny by regulators and policymakers regarding network accuracy and provider data accuracy, it is the right time to look at your current process and ask: Am I doing enough to maintain accurate data?
- Health and Ancillary Plans must maintain accurate provider data, provide up-to-date directories and use accurate data for network submissions and reviews.
- Practitioners and specialists must ensure that their data is properly submitted and updated on time.
This is where Quest Analytics can help. With our powerful solutions, you can take the first step toward establishing a streamlined, data-driven process that prioritizes accuracy and compliance. Our team of experts can work with you to identify areas for improvement. They can also develop a tailored approach that fits your organization or practice’s unique needs.
Don’t let inaccurate data hold you back. Contact us today to schedule a consultation and learn more about how we can help. Get Started
1. Open Letter to CMS on MA Rule: https://www.finance.senate.gov/imo/media/doc/021423%20Wyden%20Letter%20to%20CMS%20on%20MA%20Rule.pdf
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