It’s staggering to think that, according to researchers, one in five emergency room visits results in an individual receiving a bill for treatment or services they expected to be covered by their health plan but weren’t. These unexpected, costly and often frustrating charges are aptly called Surprise Bills. And, Congress just passed a year-end bill to rectify this practice making surprise bills illegal and requiring health providers and insurers to work together to ensure that consumers are informed and protected.
Surprise billing impacts consumers, while also affecting the satisfaction of a health plan’s members. As a result, this can impact quality ratings, prompting members to shop around for a new provider, a new plan partner or even file a complaint against their insurance company. Further, this surprise billing impacts the relationship the consumer or patient has with their provider or caregiver when they are charged for services they were not aware they were incurring for example, when an out-of-network provider such as an anesthesiologist or radiologist is involved in a patient’s care.
The Centers for Medicare and Medicaid have guidelines in place to help prevent Surprise Billing; however, employer-based, QHP and commercial plans have not received the same oversight – until now. In the final weeks of 2020, Congress pushed to eliminate surprise billing with the No Surprises Act . The Act is designed to protect patients and improve the accuracy of provider directory information. This federal mandate on provider directory accuracy impacts all private group and individual plans, bringing them into alignment with the government plan requirements. Because Provider Network Management is core to what we do, we understand what this legislation means for health plans. This legislation will require Network Managers to carefully consider their framework for managing commercial Accuracy.
Here are the Top three things you and your network management team should be discussing:
1. Health plans must establish a provider directory verification process by January 1, 2022.
Ask yourself: How are we currently verifying our provider data? At what frequency? What attributes do we verify? Do we know how many providers have not attested in the past six months?
Beginning on January 1, 2022, plans must establish a provider directory verification process. From the final language, we also know that plans will be required to verify and update their provider directory database at least once every 90 days.
Ask yourself: Do we know the age of our data? Do we track the last verified date? Do we have a process for eliminating non-verifying providers?
Under the act, Health plans will need to establish a procedure for removing providers who have not verified their personal and practice information during a period specified by the plan or insurer.
2. Health plans will be required to update their directories and respond to consumers quickly.
Ask yourself: How do we ingest updates into our provider directories? With what frequency? Do we leverage updates across all lines of business?
The new legislation requires a provider database to be made available on a plan’s website, including the providers and facilities where the health plan holds a direct or indirect contractual relationship. Along with maintaining this online provider directory, plans will be required to update their directory database within two business days of receiving an update from a provider. The law states, to protect consumers from unknowingly seeing an out-of-network provider, plans must respond to consumer directory calls within one business day of receiving a request and maintain records for a minimum of two years. Plans who fail to remove terminated providers from their directories are financially responsible for provider costs associated with providing inaccurate network status to an enrollee.
3. Providers will be required to submit information more often to health plans in order to verify accurate information.
Ask Yourself: Can we measure, manage and monitor our accuracy score? Do we know the impact our accuracy has on our network adequacy?
As for providers, the law requires them to supply their name, address, specialty, telephone number and digital contact information. Also, they must submit information to a health plan for each of the following events:
- At the time of entering into a network contract
- When a provider terminates their contract
- When there are material changes to the contact information
- Any other time determined – (including upon the request of the insurer or plan) by the provider, facility, or Secretary
The goal of Congress in eliminating surprise billing is to remove consumers who have been caught in the middle of a contractual tug-of-war between providers and their health plans while ensuring protection and overall access to care.
The Quest Enterprise Services Accuracy solution is a key component to establishing a provider directory verification process and a system that will enable the removal of providers and/or facilities with unverifiable data. We have also evolved our solutions to help our industry partners comply with the new requirements to improve their provider data accuracy. HOWEVER, once the provider directory is accurate, organizations will still need to ensure an adequate network of providers for their members. Quest Enterprise Services is the ONLY solution that can do both.
Our plan partners have made a promise to their members that they’ll have access to care when and where they need it. We help them keep that promise by providing solutions that meet the Act’s data accuracy requirements and exceed them. Our platform tells you what’s right, wrong and missing within your data while also linking that information to your network’s adequacy — benefiting the plan, its providers and its members. It takes health plans beyond just being adequate to being exceptional. At Quest Analytics, our goal is to help our plan partners keep their promises. Contact us to find out how we can help you build and sustain a more accurate and exceptional provider network.