Repression of network directories feeding online solutions


Concerned about widespread inaccuracies in network directories for health plans, lawmakers across the country are calling for more stringent data collection requirements. A mix of new state and federal regulations is forcing payers to provide consumers with up-to-date network directories of available healthcare professionals. This year alone, state law regarding the accuracy of network directories was introduced in Connecticut, Georgia, Hawaii, Illinois, Massachusetts, Maine and Texas. California enacted a Supplier Directory Act last year.

The concerns are real. According to CMS, nearly half (45%) of online Medicare Advantage provider directories are inaccurate. Plans that do not keep their directories up to date face hefty fines – up to $ 25,000 per physician error and up to $ 100 per physician for errors in plans sold on

Not keeping directories up to date can cause all kinds of problems. Without accurate information, patients risk choosing a doctor who is out of the network and not fully covered by their health plan. They may not know that the doctor is not accepting new or Medicare patients, or that the office has moved to a new location.

This has contributed to the problem of “surprise” medical bills, bills that patients receive with unforeseen costs because care has been inadvertently provided outside of their insurer’s network. A recent Commonwealth Fund study found that only six states have laws that protect consumers from billing balances for out-of-network care provided in emergency departments or network hospitals, and even those laws have loopholes.

Surprise invoices are a major symptom of poor data accuracy, says Tom Suk, senior director of vendor data solutions at LexisNexis, who has developed a product to streamline directory management. “This is one of the main reasons CMS is really repressive. “

The other concern, says Laurie McGraw, senior vice president of health solutions at the American Medical Association (AMA), is that patients will fail to follow a treatment plan if they realize they have received medication. off-grid care.

Overwhelmed by update requests

As health plans respond to these mandates, physician offices are inundated with repetitive requests for health plan data verification needed to continuously check the quality of network directories. According to the AMA, the average doctor is affiliated with 12 health plans and will undergo a rigorous data audit for each one.

Provider groups agree that consumers need accurate information on which to base their healthcare decisions, but argue that the current system of data collection is fragmented, redundant and unnecessary, contributing to administration costs health care costs of $ 361 billion a year in the United States.

“It’s problematic for both parties,” says Robert Tennant, director of health informatics policy at the Medical Group Management Association (MGMA). Plans need to ensure sufficient network access for their clients, but at the same time, doctors are struggling to meet the multiple demands. “It could be several products from different health plans … or several forms for different health products offered” by the same insurer, he told Healthcare Dive. “I have talked to people and they will tell me that they could spend all day filling out these forms.

For example, not only do laws require plans to verify data such as name, location, phone number, and whether a doctor is accepting new patients, but some, like that in California, require directories to include the proximity of a doctor to public transport, including for disabled people. .

Simplify the process

So how is the industry dealing with this? Where there is a problem there will be people trying to fix it, and network directories are no exception. Several organizations, including LexisNexis, have developed software tools that simplify the process of reporting and updating supplier data.

LexisNexis began working with AMA two years ago to improve the accuracy of network directories while reducing disruption in the office. The result, Verify HCP, allows physicians to pre-populate, collect, monitor, cleanse, and update data in real time. It also includes a multi-channel awareness campaign to meet various federal and state regulatory guidelines.

Launched 10 months ago, Verify HCP currently manages over 2 million types of vendors and installations.

The Council for Affordable Quality Healthcare (CAQH) has a supplier directory maintenance tool. Called Direct Assure, it works in conjunction with CAQH’s ProView accreditation database to allow providers to review and update self-reported data for use in network directories. The database includes over 1.3 million suppliers.

Payers are also looking into the matter. Last year, America’s Health Insurance Plans (AHIP) worked with two providers – Availity and BetterDoctor – to contact more than 160,000 providers, testing different ways to coordinate with them to update directory information. An independent evaluation identified three main opportunities for improvement: improving provider accountability through contractual requirements and other incentives; develop a set of industry-wide standards for directory data definitions, file format protocols, and other validation requirements; and improving provider engagement.

“Healthcare plans recognize that maintaining accurate supplier directories is a shared responsibility,” said Cathryn Donaldson, director of communications at AHIP, at Healthcare Dive.

One stop shop

While competition could hamper the goal of one-stop shopping, where a vendor would enter their business information just once, current efforts to streamline directory reporting are showing promise. The question remains, however, whether government insurance programs will participate in these solutions.

Medicare continues to require providers to follow its own accreditation system, PECOS, despite a high level of overlap with the industry’s ProView system, Tennant notes. The agency’s argument is the same as health plans used when they previously did not want to join forces – that CMS’s needs are different from other health plans. “The answer, of course, is you aren’t,” he says.

In an MGMA survey that has yet to be released, 94% of respondents said they prefer a single source of accreditation for Medicare, Medicaid, and commercial payers. Tennant believes the same would be true of directories. “Anytime you can harmonize these data entry requirements, it’s always better for physicians’ practices,” he says.


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