Provider Database Accuracy

Provider Database Accuracy

No Surprises Act H.R. 133-Consolidated Appropriations Act

What is the No Surprises Act?

The No Surprises Act provides consumers federal protections against surprise medical billing and limits out-of-network cost sharing under many of the circumstances in which surprise bills frequently arise. Surprise billing occurs both for emergency and non-emergency care in which the patient has no control in selecting a provider within their network.

Some examples of these circumstances include:

In emergency care, the individual may require ambulance transportation to an emergency room and go to a participating hospital or facility but receive care by a non-participating provider working at that facility

Or, in non-emergency care, the individual may choose a participating facility but not know that at least one provider involved in their care (for example anesthesiologist, diagnostic radiology, assistant surgeon, or pathologist) is a non-participating provider

These surprise bills create financial burdens for many members. For this reason, the Consolidated Appropriations Act (CAA) has included provisions regarding transparency as it relates to accuracy in a provider network. [Link]

How Will the No Surprises Act Affect You:

Effective January 1, 2022, all group/individual Health Plans must establish a provider verification process. Providers and Facilities will be required to provide consumers with a good faith estimate of costs before health care services are delivered. In addition, Health Plans will be required to establish an Independent Dispute Resolution (IDR) process that allows plans, issuers, non-participating providers, and non-participating emergency facilities to resolve disputes over out-of-network rates.

Most Common Concerns

Provider data accuracy has consistently been a challenge for health plans. Some contributing factors are:

There is no doubt, this new provision will force entities to re-examine the way they manage provider data, including what changes are needed, and how they monitor, validate and control the data to ensure compliance is met.

Health plans will now have:

Provider Data Challenges:

Managing large provider data that is manually pulled from different sources creates major concerns with data quality, such as incomplete provider entry, duplicate provider records, and missed deadlines. Provider accuracy is essential for every health care organization and can impact quality performance for some internal support departments such as claims, authorizations, customer service, and network management. It can also impact the relationships between health plans and their member’s satisfaction.

Provider Attributes:

According to a recent provider directory review conducted by The Centers for Medicare & Medicaid Services (CMS), several issues were identified resulting in a remediation plan.

Provider data accuracy has consistently been a challenge for health plans. Some contributing factors are:

Improving Provider Accuracy:

So where do we start to establish a near “perfect” database?

First, partner with a company who knows the industry and understands how to address the challenges you are facing. This partner should be able to leverage not just technology, but also operational experience to help resolve your issues.

Next, examine the processes and resources you are using to retrieve and upload provider data. Be sure to establish standard processes and procedures that will help you eliminate provider errors.

Be sure and conduct “Just in Time” training for your team and do not forget to include support team members in the process. The most effective solution is to implement an automated workflow process to handle daily provider updates. By using intelligent automation, you will improve data accuracy and turnaround time. Be sure to schedule daily and weekly quality reviews and include a remediation plan to correct errors that are identified during the audit.

Next Steps:

No Surprises Act has raised several concerns from health plans, providers, and facilities such as data transparency, timeliness, system updates, and payment accuracy. In a recent article the American Health Insurance Plans (AHIP) has requested the Department of Health and Human Services push the new requirements to 2023 to allow insurers more time to make the necessary changes. In consideration to their request, the department has pushed the Price Transparency provision to July 1, 2022, for plans and policies effective January 1, 2022. However, entities are still expected to demonstrate a high level of provider accuracy prior to this new change. [Link]

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