What to know about insurance company directory regulations under the ACA

What to know about insurance company directory regulations under the ACA

2018-01-24T12:34:00+00:00 March 22nd, 2017|Data Cleansing|

Finding a medical professional that fits people’s specific needs and wants can be a challenging process. Patients rely on their insurance provider to tell them which doctors, physicians and specialists are not only in their specific network but are accepting new patients and appointments.

As a result, it is the responsibility of health payers to ensure their provider directories are accurate and updated for consumers.

A notice from CMS
In February 2015, the Centers for Medicare & Medicaid Services issued a letter to issuers of qualified health plans on the federal marketplace under the Affordable Care Act as well as to insurers that deliver Medicare Advantage plans. Both notices focused on the need for correct information regarding the availability of medical providers.

“A QHP issuer must publish an up-to-date, accurate and complete provider directory, including information on which providers are accepting new patients, the provider’s location, contact information, specialty, medical group and any institutional affiliations, in a manner that is easily accessible,” the CMS correspondence stated.

“Records must be updated on a monthly basis.”

These records must be updated on a monthly basis and available to patients in a machine-readable format and file.

Penalties for noncompliance
To ensure health payers are completing this task, the CMS has also introduced fees that will have to be paid if insurers don’t adhere to the organization’s rules. There is a maximum $100 per day penalty for each individual negatively affected by a noncompliant QHP or dental plan as well as up to a $25,000 fine per day for marketplace beneficiaries experiencing the same thing.

Audits left to the states
Although the CMS required these directory updates, patients are still complaining about inaccuracies in the information. While the ACA and the U.S. Department of Health and Human Services enacted the rules regarding network quality, they tend to leave enforcement up to individual states in charge of their marketplaces, according to MedCity News. States may not have the resources or time to test lists for accuracy, resulting in even more problems and unhappy consumers.

The CMS aimed to make 2017 different, however. Between November 2016 and January 2017, the Medicare-Medicaid Coordination Office – in partnership with a contractor – reviewed a sample of print and online provider and pharmacy directories to locate elements needing improvement. Reviews will continue to be held in the future to improve the rules regarding these records under the CMS’ direction.

It is crucial for health payers to provide patients with up-to-date, accurate and ready-to-use information regarding healthcare providers and their availability. Managing their own databases can be a difficult task for insurance companies. HealthLink Dimensions can help by offering comprehensive data services designed to help organizations of all sizes prepare, maintain and audit their healthcare provider data on a regular basis.