Beginning next year, CMS will require health insurers to provide individuals enrolled in Medicare Advantage plans up-to-date details about those plans in real time. More specifically, health insurers will have to contact doctors and other providers every three months and update their online directories to include details about which doctors in the plan are available and taking new patients. This requirement is made even more challenging by unsettled provider conditions that exist as a result of acquisitions, mergers and consolidations; a fact of life in healthcare. Providers move practices, retire, or change their relationships with managed care organizations and fail to notify networks. Other changes affecting the market include narrower networks, new delivery models (ACOS) and new contracting reimbursement models.
All of these issues lead to the need for demographic updates but it is a challenge for organizations to do this on their own. Provider data accuracy ages the moment it hits your systems. Significant effort and activity is required to get providers to respond and to keep and track updated licenses and other information. The industry has relied primarily on credentialing; typically a monumental, in-house undertaking, and secondarily (perhaps unwisely?) on passive updates, where providers are contractually required to provide specific updates. Different organizations and networks credential with varying degrees of aggressiveness and success.
The hard truth is that the old methods aren’t working. Health plans are going to be forced to become more aggressive in keeping data updated, either by building out infrastructure or by partnering with entities already meeting the new standards. Accurate provider data and an ability to dish this information up in real time are rapidly becoming product differentiators in the era of healthcare reform.