Expanding Focus on Provider Directories

A Closer Look at the Key Issues

Expanding Focus on Provider Directories

A Closer Look at the Key Issues

Sanator Roster Reporting

Sanator reports provider directory updates to health plans on a weekly basis. Download the SRR  specification here.

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Regulatory Developments

Regulations from multiple agencies are slowly aligning across Medicare, Medicaid and Commercial health insurance products.

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Federal and State Regulations

Federal and state entities are focusing on Provider Directories and defining regulations. Understanding these rules is imperative.

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Meeting Consumer Expectations

Consumers expect accurate information, transparency, convenience and a higher degree of service.

Consider the comparison of shopping on Amazon vs. Covered California

It is difficult to imagine consumers spending thousands of dollars on any product or service without extensive online shopping tools, product research and service guarantees. Yet, inaccuracies in provider directories create this very situation for millions of American consumers.

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Source: Manatt Health

"One day, I might be in employer-sponsored coverage. The next day, I might be in an exchange, and ultimately, I'm going to be in Medicare. I shouldn't have to relearn how the world works every time I move from payer to payer. The payers feel this way as well."

- Marilyn Tavenner, AHIP's CEO and former CMS Administrator

"One day, I might be in employer-sponsored coverage. The next day, I might be in an exchange, and ultimately, I'm going to be in Medicare. I shouldn't have to relearn how the world works every time I move from payer to payer. The payers feel this way as well."

- Marilyn Tavenner, AHIP's CEO and former CMS Administrator

Federal and NAIC Guidance for the Consumer Experience

Qualified Health Plans

Healthcare.gov and some SBMs are making progress providing consumers with integrated provider directories, but many challenges still remain

Medicaid Managed Care

Most recent guidance requires machine readable formats to improve transparency and provide an opportunity for third party aggregation of information (for the benefit of consumers)

Medicare Advantage

Machine readable formats may be required in the future are not currently required. Defines machine readable as “a format in a standard computer language (not English text) that can be read automatically by a web browser or computer system.” This showcases the need for consistent definitions and standardization

A Closer Look at Regulatory Developments

Qualified Health Plans

  • Marketplace rules have regulated provider directories since 2014.
  • Rules were substantially strengthened by the 2016 payment notice, which added the machine readable requirement for FFM carriers.
  • 2017 rule offered additional guidance.

Medicare Advantage

  • 2016 Final Call Letter requires carriers to update identified errors within 30 days and conduct quarterly outreach to providers.
  • 2016 Final Call Letter first raised the desire for requirement alignment across programs (QHP, MA, MMC); reiterated that changes related to alignment around data elements and machine readability are likely.
  • No changes have been proposed yet; call letters note that MA is currently farthest behind.

Medicaid Managed Care

The 2016 managed care rule added many new provider directory requirements including:

  • Frequent updates (within 30 days of receiving new provider information)
  • Active monitoring by Medicaid managed care organizations for accuracy
  • Machine readable

NAIC Model Act

  • In November 2015, the NAIC adopted revisions to its network adequacy model act (#74).
  • Act includes a new section with provider directory requirements for insurers, including a consumer redress provision.
  • CMS and NAIC/states continue to position for leadership on network adequacy and provider directory requirements.
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Federal and NAIC Carrier Duties

It's important to understand the rules for maintaining an accurate provider directory, as the repercussions of inaccuracy can be significant

Qualified Health Plans

  • Publish up-to-date, accurate, complete, provider directory online that is easily accessible to the general public
  • Update at least monthly
  • Share link with CMS to be published on FFM
  • Make the provider directory available in specified machine readable format
  • Machine readable formats must be publicly discoverable to allow third parties to develop unique interfaces

Medicare Advantage

  • Provide paper copy of directory or paper notice describing where the enrollee can find the directory online and how the enrollee can request a hard copy
  • Maintain online provider directory
  • Correct identified errors within 30 days
  • Conduct quarterly outreach to providers

Medicaid Managed Care Organizations

  • Make provider directory available on plan website in a machine readable format
  • Update online version within 30 days of receiving new provider information
  • Provider paper version upon request, free of charge and within 5 days
  • Update paper version monthly
  • Maintain directory in “prevalent” non-English languages
  • Include auxiliary aids for deaf and blind individuals

NAIC

  • Publish searchable, online provider directory that is easily accessible to the general public
  • Update directory at least monthly
  • Provide print copy available upon request
  • Accommodate the communication needs of individuals with disabilities and provide additional information to assist those with limited English proficiency
  • Do periodic audit of reasonable sample size for accuracy

Regulator Roles

Qualified Health Plans

  • CMS enforces QHP rules (including directory rules) in FFM states and states enforce in SBM states
  • General enforcement rules apply to non- QHP-specific rules: states are primary enforcers as long as “substantially enforcing” the law
  • CMS can impose civil penalties of up to $100 per day per violation
  • No federal enforcement actions to date

Medicare Advantage

  • Identification of non- compliance with provider directory requirements through monitoring and auditing processes could result in enforcement actions, including civil money penalties or enrollment sanctions

Medicaid Managed Care Organizations

  • State regulators are responsible for enforcement and can audit provider directories

NAIC

  • Provide audit documentation upon request
  • Penalties left to states to determine (NY has reached settlements with more than a dozen carriers since 2010)

Guidelines: Federal and NAIC Data Elements

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NAIC Model Act

The NAIC Model Act references additional carrier duties, naming some of the ways states can go further than the current federal requirements.

NAIC Model Act

The NAIC Model Act references additional carrier duties, naming some of the ways states can go further than the current federal requirements.

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Are you compliant?

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