No Surprises Act Notification to Providers
As of Jan. 1, 2022, Section 116 of the Federal Consolidation Appropriations Act, often referred to as the “No Surprises Act”, or NSA, which protects patients from unexpected medical bills, became effective.
Besides trying to ensure there are no surprise bills received by patients from out-of-network providers, this act addresses Provider Directory Accuracy and regulates the responsibility of payers so that providers understand their obligations for the provider information that appears in all Payer provider directories.
Provider Directory Requirements in the Affordable Care Act
The ACA and corresponding regulations put in place certain requirements for Qualified Health Plans to make provider network information transparent. In addition to general network adequacy standards, the law requires that plans “provide information to enrollees and prospective enrollees on the availability of in-network and out-of-network providers.
Inaccuracies in Provider Directories are Prevalent
Consumers often find that reliable information about health insurance provider networks is not available. Common inaccuracies contained in the provider directories maintained by health plans include:
- Providers who are not actually in the plan’s network
- Inaccurate provider contact information, such as incorrect phone numbers
- Inaccurate information about which languages providers speak or the type of health care services they deliver
To ensure compliance, several requirements for both payers and providers came from this act:
For Payers:
- No less frequently than once every 90 days, payers must verify and update the provider directory information of providers.
- That payers establish a process to remove providers from directories if the payer cannot verify the provided information.
For Providers:
- Providers shall submit provider directory information to a plan or issuers, at a minimum:
- When providers terminate a network agreement.
- When there are material changes to the content of provider directory information.
- At any other time (including upon the request of such issuer or plan).
- Current CMS/HHS regulations are still in effect and contractual obligations to notify all Health Plans of provider changes still apply.
- Incentive payment eligibility, with many payors, is contingent upon quarterly provider directory verification.
Payors and third-party vendors will be reaching out at the beginning of each quarter to verify that your provided information is accurate. Each practice and provider is responsible to ensure this information is accurate at the time of each request.
Depending on the insurance company, you may review and update your information in the payors’ provider directory portal or via a communication to the payor or through a third party vendor such as:
- LexisNexis
- BetterDoctor
- Availity
- Navigate
- CAQH
- and others
The following are directory and member best practices that align with how patients interact with your office. When reviewing and verifying information with payers, please keep in mind:
- Office Name: This should reflect how the phone is answered, as well as apparent signage of the office.
- Street Address: The street address should include the address in full, including Suite #, Floor, and all information for where members would visit.
- Office Phone Number: This is the number that members call to make an appointment. Your fax number should also be included
- Ability to Accept New Patients: This includes seeing new patients and seeing new patients by referral only.
- Office Hours: The listed hours should be when the office is available for members to make appointments and see providers.
- Hospital Privileges: This should reflect In-Network hospitals where providers have privileges to treat members.
- Other Information: Additional information may be required to be verified, such as languages spoken, specialty.
Best Practice examples of this information:
- The regulatory agencies anticipate that a provider office would answer a member phone call with a greeting that is consistent and repeatable to all callers, and this office name would be equal to the office name verified in directory attestation efforts.
- Not including providers in the directory if they only work at a hospital location and aren’t available for office visits
- Not including providers that serve as on-call and substitute providers and aren’t regularly available to provide care at an office or practice location
- Listing only providers who regularly practice at the specific location
- Have staff use the same terminology consistently so all clinic staff communicate clearly to patients
- Ensure everyone in the office that answers the phone has the same information and communicates the same.
Rationale for this legislation
Consumers need accurate information about the providers and facilities that are in health plan provider networks when shopping for coverage. Health plan enrollees need accurate information about which providers and facilities they can visit in-network.
Accurate information is necessary for consumers, regulators, and lawmakers to assess the adequacy of an insurer’s network.
Consumers often find that reliable information about health insurance provider networks is not available. Common inaccuracies contained in the provider directories maintained by health plans include:
- Providers who are not actually in the plan’s network
- Inaccurate provider contact information, such as incorrect phone numbers
- Inaccurate information about which languages providers speak or the type of health care services they deliver
Please also keep in mind any other information that affects your patient availability. This aligns with CMS, other regulatory expectations, and values which are subject to regulatory audit accuracy efforts of insurance companies in their efforts to ensure their provider directories are accurate. Insurance companies will surely hold providers and practices accountable for this accurate information.
The federal government can fine insurance companies if they do not maintain accurate provider directories and we can predict that these fines may be passed down to providers and their practices which do not maintain their information accurately with the potential of having contracts and credentialing terminated if directories are not maintained.
Check back in for updates on the No Surprises Act, and call (717) 691-6768 for other healthcare consulting information, or schedule an appointment here.