Navigating Provider Directory Accuracy Regulations
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Provider directory accuracy is critical to ensuring consumers get the care they need from the right doctors. The challenge is the rate at which provider data changes and getting that information into the hands of members. Now regulatory bodies are demanding health insurers put processes in place that ensure the information they collect and publish to their member populations is current and complete. Updating mandatory data fields like address, acceptance of new patients, specialty, languages spoken and more can become overwhelming for a health plan – putting a strain on resources. LexisNexis explores where regulations stand, the nature of provider data and why maintaining it is a challenge, and a proven approach to managing your provider data and directories.
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Navigating Provider Directory Accuracy Regulations
- 1. Navigating Provider Directory Accuracy Regulations Webinar Presented by LexisNexis February 24, 2016 This presentation cannot be duplicated or reproduced in part or in whole without written consent from LexisNexis. Copyright © 2016 LexisNexis. All rights reserved.
- 2. Agenda • Introductions • Overview of where regulations stand • Discussion around the challenge with maintaining provider data • Explore a proven approach to managing provider information 2
- 3. Speakers 3 Josh Schoeller VP, Client Engagement LexisNexis Health Care Tom Suk Sr. Director, Provider Data Solutions LexisNexis Health Care
- 4. Where the Rules and Regulations Stand 4Private & Confidential
- 5. Affordable Care Act Provider Directory Mandate THE CHALLENGE: Payers need support to respond to evolving regulations—or face penalties Confidential and Proprietary 5
- 6. What is driving this Directory Accuracy Need? Confidential and Proprietary 6 Simply Put: Inaccuracies have caused patients to be billed for costly out-of-network charges “Now that people have choices and can shop between plans, provider directories take on a much more important role,” said Anthony Wright, executive director of Health Access California, a health care consumer advocacy group. “We don’t allow grocery stores to sell products with inaccurate food labeling. ... We can’t have a functioning insurance market if consumers don’t know what they are buying.”2 Sources: 1 http://www.sacbee.com/news/local/health-and-medicine/healthy-choices/article42775785.html#storylink=cpy 2 http://www.sacbee.com/news/local/health-and-medicine/healthy-choices/article42775785.html#storylink=cpy One major payer has already paid more than $38 million in refunds to affected patients1
- 7. Sources: 1 https://www.cms.gov/CCIIO/Resources/Regulations-and-Guidance/Downloads/2016-Letter-to-Issuers-2-20-2015-R.pdf 2 11/13/15 CMS memo, subject "Provider Directory Requirements - Update" Qualified Health Plans (QHPs) and Stand-Alone Dental Plans (SADP) requirements1 Medicare Advantage, Medicare-Medicaid Plans, Section 1876 Cost Plans, Prescription Drug Plan Sponsors 2 Electronic provider directories updated monthly Update directories at least every 30 days Directories must note whether provider is currently accepting new patients Conduct quarterly outreach to contracted providers to ensure Other provider directory elements must include: provider name, location, contact information, specialty, group affiliations Directories must note whether provider is currently accepting new patients Other provider directory elements must include: provider name, location, contact information, specialty, network participation CMS is Pushing for Provider Directory Accuracy Confidential and Proprietary 7
- 8. Non-compliance can be Costly 1 Kaiser Health News, March 9, 2015 http://khn.org/news/health-exchange-medicare-advantage-plans-must-keep-updated-doctor-directories-in-2016/ Inaccuracies in the Medicare Advantage directories may trigger penalties of up to $25,000/day/beneficiary or bans on new enrollment and marketing1 The federal exchange plans could face penalties up to $100/day/beneficiary for problems in their directories1 Confidential and Proprietary 8
- 9. New State Rules for Provider Data Accuracy All but 12 states have adopted specific provider directory requirements for some types of state health plans Roughly half of all states specify updates are necessary, most noting the frequency of updates In addition to Medicare Advantage plans, four states—CA, MD, NJ, VT—and DC require proactive verification of provider directory elements California recently enacted SB137, which requires that the plan: • Investigate any reported inaccuracies within the provider directory within 30 days • Review and update the entire provider directory by contacting all contracted providers for verification at least annually Confidential and Proprietary 9
- 10. Additional Legislative Changes at Both the State and Federal Levels are Expected Source: http://www.naic.org/store/free/MDL-74.pdf Electronic provider directories be updated at least monthly Plans should consider contacting participating providers who have not submitted a claims within 6 months in order to confirm participation Periodic audit of a sample of the provider directory to verify accuracy Directories must note whether provider is currently accepting new patients Other provider directory elements must include: provider name, location, contact information, provider gender, affiliations, specialty and languages spoken National Association of Insurance Commissioners (NAIC) released their recommendations for provider directory rules Confidential and Proprietary 10
- 11. Poling Question 1: How is your organization addressing these new mandates? • Using internal solution • Working with a vendor • Not currently acting, waiting for further clarity on regulations 11
- 12. The Provider Data Challenge 12
- 13. 0% 50% 100% 3 6 9 12 15 18 Bad Good Provider demographic data quality degrades rapidly • Human errors in data entry • Multi-channel delivery of incoming transactions with errors/omissions • Data integration challenges across data sources/organizational silos • 2.4% of provider demographics change each month • 30% of doctors change affiliations each year • 5% of doctors change status each year Provider Data is Changing all the Time The provider universe is always changing The pace of business leads to additional inaccuracies Months Confidential and Proprietary 13
- 14. How Much Does Data Really Change in a Week? • 33,000 primary addresses • 3,300 names • 1,750 phones • 1,500 fax numbers In the time we spent on this slide, your provider data went out of date. • 86,000 state license expirations • 17,000 state license statuses • 7,000 Qualifiers • 1,000 DEA numbers How do you keep your provider data current? How do you know if providers are in good status? Confidential and Proprietary 14
- 15. Significant errors in payers’ files Quality Problem Average % duplicate records 8.56% % missing or bad phone numbers 23.56% % bad addresses 18.26% % sanctioned providers 2.49% % retired providers 0.56% % deceased providers 0.71% Based on over 200 representative client network files (2014, 2015) 15Confidential and Proprietary On Average, Payers in the U.S. are Between 55% and 70% Accurate on Critical Directory Fields Access Problem Average % of providers reporting not participating / accepting new patients 29.69% - 9.27% Based Jan 2016 verification results to date across plans
- 16. What are Providers Thinking? Confidential and Proprietary 16
- 17. Why is Updating Provider Directories so Hard? Confidential and Proprietary 17 Provider data systems are vast, dispersed and not integrated The landscape is constantly changing The insurance industry is filled with complexity 1 2 3
- 19. What is the Best Way to Fix this Problem? Confidential and Proprietary 19 “Baseline” your provider directory Make it easy for a provider to attest Allow a provider to attest for multiple payers and network plans Monitor your directory population Employ the right technology • Cleanse your directory for de-dups, purge outdated and obsolete information (i.e. Deceased physicians) • Assign a persistent ID (not just NPI) to each provider so that subsequent information changes can quickly be applied • With the ability to process data quickly to ensure timely updates • Check your directory for changes as changes are discovered for the provider (i.e., new locations, detect new Medicare claims activity, flag no Medicare activity, etc.) • Allow multiple ways for a the provider or office manager to attest their information through a channel that they prefer • A comprehensive, single approach where a provider can be contacted once to attest for multiple payers is critical
- 20. A Complete Solution Requires 5 Critical Components • Network (provider files) • Plan Participation (under contract) • Contributed Claims Conducts campaign outreach, including email, fax, call, direct mail • Leverages > 2,000 sources to build the “best” view of a provider • Covers more than 8.5M providers Provider Data MasterFile Multi-Channel Outreach and Data Stewards Payer Consortium • Simple enablement tool for streamlined provider self-attestation • Internal – could enhance existing app (Calling App, Feedback App) • External – build and/or partner with vendors Provider Portal Ongoing monitoring of plan activity and tracking recency/frequency Claims Data Confidential and Proprietary 20
- 21. Sourcing Components: A Contributory Model Payer Consortium Provider Network Files Enable triggered validation of new locations Reduce latency Network / Product Tags Enable dynamic selection of applicable networks for validation Direct Client Feedback Loop Profile updates leverages across payers Confidential and Proprietary 21
- 22. Poling Question2: How willing would your organization be to participating in a consortium? • Very likely – understand the value • Possibly – need to understand the benefits more clearly • Not at all 22
- 23. Sourcing Components: Master Provider Database Provider Data MasterFile Data Sources, Advanced Analytics, Verification • Continuously updated profiles • Authority and transactional sources used so each attribute is accurate • Analytic models target calls to those most likely to have changed Sophisticated Algorithms Maximize record matching while limiting false positives Customization, Health Care Expertise Confidential and Proprietary 23
- 24. Sourcing Components: Claims Enabled Near Real-Time Monitoring Claims Data Leverage Transactional Data Stream to Monitor Latency and Reduce Risk Monitor providers at practice locations and correlated billing entities Alert to new locations and provider changes Track recency and frequency Confidential and Proprietary 24
- 25. Sourcing Components: Leveraging Current Provider Touchpoints Provider Portal Customized Portal for Directed Data Capture Dynamically serves up required verification: • Demographics • Network/product participation • Ability to customize for incremental access required elements Open API Connection for Existing and Industry Portals Leverage existing touchpoints Enablement of existing system(s) with augmented external data • Capture new touchpoints Confidential and Proprietary 25
- 26. Multi-Channel Outreach and Data Stewards Sourcing Components: Multi-Channel Outreach and Data Capture Enable Scalable Direct Outreach Verification Phone: • Leverage U.S.-based and/or overseas capabilities Triggered based on tracked verification requirements and external triggers to optimize accuracy Alternative contact mediums to maximize responses: • Phone, fax, email, portal, a web app Confidential and Proprietary 26
- 27. Directory Accuracy Competing objectives require a complete and balanced solution 27 Compliance: A balancing act for the payer Network Adequacy Medical Loss Ratio The Challenge Confidential and Proprietary
- 28. For More Information Josh Schoeller VP, Client Engagement O: 678.694.2004 Josh.Schoeller@lexisnexis.com Linkedin.com/company/lexisnexis-risk-solutions Youtube.com/user/lexisnexisnetwork Twitter.com/lexisnexisrisk Facebook.com/lexisnexisrisk 28 This presentation cannot be duplicated or reproduced in part or in whole without written consent from LexisNexis. Copyright © 2016 LexisNexis. All rights reserved.