Federal Governments Requirements for QHPs and Provider Directories – Don’t Panic (Yet).

Vice President
Josh Holmes

Josh Holmes

What You Need to Know:

On Feb. 20, 2015, 2015 the Centers for Medicare & Medicaid Services (CMS) released two distinct rules regarding online directories.  According to the rule, Medicare Advantage Organizations will be required to contact providers on a quarterly basis (90 days) beginning next year and be expected to update online directories in real-time.

The rule also states that for MAOs to be compliant with § 422.111, they must “include in their online provider directories all active contracted providers, with specific notations to highlight those providers who are closed or not accepting new patients.”

Note that the second rule regarding QHPs in the health insurance exchange does not utilize the phrase “real-time.”  The rule states that a “provider directory will be considered up-to-date if it is updated at least monthly and easily accessible when the general public is able to view all of the current providers for a plan in the provider directory on the issuer’s public website through a clearly identifiable link or tab without having to create or access an account or enter a policy number.”

What You Need to Do Right Now:

Evaluate your credentialing and provider relations capabilities.  Do you have the staff and technology to allow you to effectively contact every provider with whom you have a contract? Can you ramp up operations in time to meet the requirements?  Do you currently outsource this function or should you consider outsourcing to a partner with scale?  If you don’t have the ability to add tech, staff and infrastructure, you need to find a partner who already does.

 Evaluate your end user experience. How easy/difficult is it for individuals to identify their program, coverages and eligible, participating providers?  Can your online portals connect individuals to the right providers on the first try, every time?  Is this info available to plan members on multiple devices?  Do you have the tech to support that kind of initiative?  If members can’t easily step through a provider search and get accurate provider details, you could be looking at fines of up to $25,000 a day per beneficiary.  If user experience and app building are not in your wheelhouse, find a partner who is already doing this in healthcare.

Evaluate your tech and data.  Can you:

“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 to plan enrollees, prospective enrollees, the State, the FFM, HHS, and OPM.”

Do you collect the necessary information regularly enough and can you turn it out to the health insurance exchange operated by the federal government in 37 states—on a monthly basis?  Do you have the time, staff and financial wherewithal to create the necessary infrastructure to meet these evolving federal requirements and continue to be profitable?  Unless you are one of the healthcare giants, the “do-it-yourself” approach is probably out of the question.  Look for a partner who can pull together and synchronize your different data sources. They should offer a platform that is compatible with other systems and platforms you already use and should be able to provide custom outputs based on your organizations specific plans and client requirements.

Don’t Panic

There is a lot of work ahead for any organization trying to keep up with federal regulations on provider data requirements, but there is still time.  Evaluating your own capabilities and beginning the search for partners who will in the gaps should be happening now.

What to look for in a solution partner.

  1. Healthcare focused, first and foremost
  2. Cloud based platform – reduces implementation time and costs
  3. Data integrity – able to take your provider info, fill in the gaps and turn it back to you squeaky clean
  4. Platform agnostic – able to integrate with other solutions you already use without massive custom programming
  5. Tailored experience – customizable and will take your branding
  6. Enables dynamic network building
  7. Has proven tools to get the right info into end user hands
  8. Two magic words – “Real Time”

Future Tense

These requirements continue to increase the pressure on plans operating in the Medicare Advantage and government healthcare exchange arena. It also represents a tremendous opportunity because CMS anticipates that a common format and standard will enable greater interoperability across provider directories and more up-to-date information in provider directories maintained by health plans, at a state level, and in national databases such as the National Plan and Provider Enumeration System.  This means that CMS is aiming for a user-friendly aggregate date source.  Developers who are early movers can take advantage of the need for user-friendly search applications that will be more accessible, up-to-date, and useful for consumers than the current, non-standardized websites or printed provider directories.  Companies that participate in reinventing how healthcare information flows will be positioned for growth in the near and long term.

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