Navigating Provider Directory Accuracy Regulations

Webinar Presented by LexisNexisFebruary 24, 2016

This presentation cannot be duplicated or reproduced in part or in whole without written consent from LexisNexis. Copyright © 2016 LexisNexis. All rights reserved.

Agenda

• Introductions

• Overview of where regulations stand

• Discussion around the challenge with maintaining provider data

• Explore a proven approach to managing provider information

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Speakers

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Josh SchoellerVP, Client EngagementLexisNexis Health Care

Tom SukSr. Director, Provider Data SolutionsLexisNexis Health Care

Where the Rules and Regulations Stand

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Affordable Care Act Provider Directory Mandate

THE CHALLENGE:

Payers need support to respond to evolving regulations—or face penalties

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What is driving this Directory Accuracy Need?

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Simply Put: Inaccuracies have caused patients to be billed for costly out-of-network charges

“Now that people have choices and can shop between plans, provider directories take on a much

more important role,” said Anthony Wright, executive director of Health Access California, a

health care consumer advocacy group. “We don’t allow grocery stores to sell products with inaccurate

food labeling. ... We can’t have a functioning insurance market if consumers don’t know what they

are buying.”2

Sources:

1 http://www.sacbee.com/news/local/health-and-medicine/healthy-choices/article42775785.html#storylink=cpy2 http://www.sacbee.com/news/local/health-and-medicine/healthy-choices/article42775785.html#storylink=cpy

One major payer has already paid more than $38 million in refunds to affected

patients1

Sources: 1 https://www.cms.gov/CCIIO/Resources/Regulations-and-Guidance/Downloads/2016-Letter-to-Issuers-2-20-2015-R.pdf2 11/13/15 CMS memo, subject "Provider Directory Requirements - Update"

Qualified Health Plans (QHPs) and Stand-Alone Dental Plans (SADP) requirements1

Medicare Advantage, Medicare-Medicaid Plans, Section 1876 Cost Plans, Prescription Drug Plan Sponsors 2

Electronic provider directories updated monthly

Update directories at least every 30 days

Directories must note whether provider is currently accepting new patients

Conduct quarterly outreach to contracted providers to ensure

Other provider directory elements must include: provider name, location, contact information, specialty, group affiliations

Directories must note whether provider is currently accepting new patients

Other provider directory elements must include: provider name, location, contact information, specialty, network participation

CMS is Pushing for Provider Directory Accuracy

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Non-compliance can be Costly

1 Kaiser Health News, March 9, 2015http://khn.org/news/health-exchange-medicare-advantage-plans-must-keep-updated-doctor-directories-in-2016/

Inaccuracies in the

Medicare Advantage directories

may trigger penalties of up to

$25,000/day/beneficiary or bans on new enrollment

and marketing1

The federal exchange plans

could face penalties up to

$100/day/beneficiary for problems in

their directories1

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New State Rules for Provider Data Accuracy

All but 12 states have adopted specific provider directory requirements for some types of state health plans

Roughly half of all states specify updates are necessary, most noting the frequency of updates

In addition to Medicare Advantage plans, four states—CA, MD, NJ, VT—and DC require proactive verification of provider directory elements

California recently enacted SB137, which requires that the plan: • Investigate any reported inaccuracies within the provider directory within 30 days• Review and update the entire provider directory by contacting all contracted providers for

verification at least annually

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Additional Legislative Changes at Both the State and Federal Levels are Expected

Source: http://www.naic.org/store/free/MDL-74.pdf

Electronic provider directories be updated at least monthly

Plans should consider contacting participating providers who have not submitted a claims within 6 months in order to confirm participation

Periodic audit of a sample of the provider directory to verify accuracy

Directories must note whether provider is currently accepting new patients

Other provider directory elements must include: provider name, location, contact information, provider gender, affiliations, specialty and languages spoken

National Association of Insurance Commissioners (NAIC) released their recommendations for provider directory rules

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Poling Question 1: How is your organization addressing these new mandates?

• Using internal solution

• Working with a vendor

• Not currently acting, waiting for further clarity on regulations

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The Provider Data Challenge

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0%

50%

100%

3 6 9 12 15 18

Bad Good

Provider demographic data quality degrades rapidly

• Human errors in data entry• Multi-channel delivery of incoming transactions with errors/omissions• Data integration challenges across data sources/organizational silos

• 2.4% of provider demographics change each month• 30% of doctors change affiliations each year• 5% of doctors change status each year

Provider Data is Changing all the Time

The provider universe is always changing

The pace of business leads to additional

inaccuracies

Months

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How Much Does Data Really Change in a Week?

• 33,000 primary addresses

• 3,300 names

• 1,750 phones

• 1,500 fax numbers

In the time we spent on this slide, your provider data went out of date.

• 86,000 state license expirations

• 17,000 state license statuses

• 7,000 Qualifiers

• 1,000 DEA numbers

How do you keep your provider data current?

How do you know if providers are in good status?

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Significant errors in payers’ files

Quality Problem Average

% duplicate records 8.56%

% missing or bad phone numbers 23.56%

% bad addresses 18.26%

% sanctioned providers 2.49%

% retired providers 0.56%

% deceased providers 0.71%

Based on over 200 representative client network files (2014, 2015)

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On Average, Payers in the U.S. are Between 55% and 70% Accurate on Critical Directory Fields

Access Problem Average

% of providers reporting not participating / accepting new patients

29.69% -9.27%

Based Jan 2016 verification results to date across plans

What are Providers Thinking?

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Why is Updating Provider Directories so Hard?

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Provider data

systems are vast,

dispersed and not

integrated

The landscape is constantly changing

The insurance industry is filled with complexity

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A Proven Approach

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What is the Best Way to Fix this Problem?

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“Baseline” your provider directory

Make it easy for a provider to attest

Allow a provider to attest for multiple payers and network plans

Monitor your directory population

Employ the right technology

• Cleanse your directory for de-dups, purge outdated and obsolete information (i.e. Deceased physicians)

• Assign a persistent ID (not just NPI) to each provider so that subsequent information changes can quickly be applied

• With the ability to process data quickly to ensure timely updates

• Check your directory for changes as changes are discovered for the provider (i.e., new locations, detect new Medicare claims activity, flag no Medicare activity, etc.)

• Allow multiple ways for a the provider or office manager to attest their information through a channel that they prefer

• A comprehensive, single approach where a provider can be contacted once to attest for multiple payers is critical

A Complete Solution Requires 5 Critical Components

• Network (provider files)• Plan Participation (under contract)• Contributed Claims

Conducts campaign outreach, including email, fax, call, direct mail

• Leverages > 2,000 sources to build the “best” view of a provider• Covers more than 8.5M providers

Provider Data MasterFile

Multi-Channel Outreach and Data Stewards

Payer Consortium

• Simple enablement tool for streamlined provider self-attestation• Internal – could enhance existing app (Calling App, Feedback App)• External – build and/or partner with vendors Provider Portal

Ongoing monitoring of plan activity and tracking recency/frequency

Claims Data

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Sourcing Components: A Contributory Model

Payer Consortium

Provider Network Files

Enable triggered validation of new locations

Reduce latency

Network / Product Tags

Enable dynamic selection of applicable networks for validation

Direct Client Feedback Loop

Profile updates leverages across payers

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Poling Question2: How willing would your organization be to participating in a consortium?

• Very likely – understand the value

• Possibly – need to understand the benefits more clearly

• Not at all

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Sourcing Components: Master Provider Database

Provider Data MasterFile

Data Sources, Advanced Analytics, Verification

• Continuously updated profiles• Authority and transactional sources used

so each attribute is accurate• Analytic models target calls to those

most likely to have changed

Sophisticated Algorithms

Maximize record matching while limiting false positives

Customization, Health Care Expertise

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Sourcing Components: Claims Enabled Near Real-Time Monitoring

Claims Data

Leverage Transactional Data Stream to Monitor Latency and Reduce Risk

Monitor providers at practice locations and correlated billing entities

Alert to new locations and provider changes

Track recency and frequency

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Sourcing Components: Leveraging Current Provider Touchpoints

Provider Portal

Customized Portal for Directed Data Capture

Dynamically serves up required verification:• Demographics• Network/product participation• Ability to customize for incremental access

required elements

Open API Connection for Existing and Industry Portals

Leverage existing touchpoints

Enablement of existing system(s) with augmented external data• Capture new touchpoints

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Multi-Channel Outreach and Data Stewards

Sourcing Components: Multi-Channel Outreach and Data Capture

Enable Scalable Direct Outreach Verification

Phone:• Leverage U.S.-based and/or overseas

capabilities

Triggered based on tracked verification requirements and external triggers to optimize accuracy

Alternative contact mediums to maximize responses:• Phone, fax, email, portal, a web app

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Directory Accuracy

Competing objectives require a complete and balancedsolution

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Compliance: A balancing act for the payer

NetworkAdequacy

MedicalLoss Ratio

The Challenge

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For More Information

Josh SchoellerVP, Client EngagementO: 678.694.2004Josh.Schoeller@lexisnexis.com

Linkedin.com/company/lexisnexis-risk-solutions

Youtube.com/user/lexisnexisnetwork

Twitter.com/lexisnexisrisk

Facebook.com/lexisnexisrisk

28This presentation cannot be duplicated or reproduced in part or in whole without written consent

from LexisNexis. Copyright © 2016 LexisNexis. All rights reserved.