5/5/2021 0 Comments
by Joey Kennedy
The No Surprises Act was signed into law on December 27, 2020 as part of the Consolidated Appropriations Act of 2021 (H.R. 133; Division BB – Private Health Insurance and Public Health Provisions). The No Surprises Act addresses “surprise” medical billing at the federal level. Out-of-network billing, or “surprise medical bills” are usually the balance between what the individual’s insurer pays for the out-of-network care and what the provider charges for the services.
Simply put, the act states that patients should not be responsible for out-of-network costs they did not agree to pay.
The Departments of Health and Human Services, Treasury, and Labor will be releasing regulations and guidelines for the implementation of these provisions before the largest sections of the legislation go into effect on January 1, 2022.
The impetus for change
The legislation is designed to address the challenge for patients which result from receiving unexpected medical bills attributed to gaps in insurance coverage for medical services provided by out-of-network providers at an in-network facility or hospital. This occurs most commonly from Emergency Department (ED) visits and second most commonly in-network hospital admissions.
A study from the Kaiser Family Foundation (KFF), found that the number amount of “surprise medical billing” for ED visits increased from 32.3% to 42.8%. and increased from 26.3% to 42.0% for inpatient admissions between 2010 to 2016. KFF estimated that an 18% of ED visits and 16% of inpatient hospital visits resulted in a minimum of one out-of-network medical bill.
What you need to know
The “No Surprises Act” calls for price transparency, consent for out-of-network costs, and accurate, accessible provider directory data.
The provider data management takeaway is that health plans will be required to establish a verification process to ensure accurate provider directories. In addition, they will need to enable a response protocol for individuals inquiring about the network status of a provider, and they are required to have publicly accessible provider databases.
Here are some additional highlights of what is required from providers and health plans effective January 1, 2022.
The American Hospital Association (AHA) provides a detailed summary of the legislation which can be downloaded here.
Provider Data Management approach to assist in “No Surprises”
This comprehensive legislation addresses surprise medical billing at the Federal level also creates an additional burden for provider data management as defined in these three sections.
SECTION 107: Transparency regarding in-network and out-of-network deductibles and out-of-pocket limitations on health coverage identification cards.
Reproduce digital and printed health coverage ID cards (health tickets) with clear cost transparency on all plan deductibles, including in-network and out-of-network deductible amounts; and the maximum limits on out-of-pocket costs, including in-network and out-of-network out-of-pocket cost limits.
In addition, it is required to include a telephone number and web address for consumer assistance information, including information on in-network providers
Enable digital data capture of consumer data and corresponding plan information via an online self-service health coverage ID solution. Ensure the visibility of all plan deductibles and out-of-pocket limits along with a telephone number and web address for consumer assistance.
SECTION 114: Maintenance of price comparison tool
Maintain online price comparison tools that will allow patients to compare expected out-of-pocket costs for items and services across multiple providers.
SECTION 116: Protecting patients and improving the accuracy of provider directory
Health plans will be required to establish a verification process to ensure accurate provider directories. In addition, they will need to enable a response protocol for individuals inquiring about the network status of a provider, and they are required to have publicly accessible provider databases.
Perspecta is uniquely positioned to support health plans and providers in meeting and exceeding these new legislative requirements before the 2022 deadline. Perspecta is a provider data management industry leader, offering solutions that deliver optimized user experience, data accuracy, access, regulatory compliance, and return on investment.
P.S.: If you have questions about how the No Surprises Act, I'd be happy to chat and provide a FREE consultation. Feel free to schedule a meeting with me here.
by Sean Healy...
Provider referrals management is a strategic balance of getting the best clinical outcomes while controlling overall claims cost. This starts by creating and managing a high-functioning provider and partner referral network to ensure beneficiaries and members receive the best in-network care when and where they need it.
Ensure a high-performing referral network
Referral networks should be measured on clinical outcomes, ancillary utilization, and proximity to the beneficiary or member. High-quality providers offer the lowest-cost and appropriate, high quality care. As such, claims adjusters and case managers need a way to quickly identify providers that match the beneficiary’s coverage plan to find the best specialists and ancillary providers that offer accessible appointments and locations.
Enable provider and partner referral insights
Data and analytics help to optimize referrals management by continuously assessing the referral network. Analytics data can provide claims managers and care managers with clear insights into why and when beneficiaries should be referred to a particular provider and which partner offers the most efficient and cost-effective service. Prioritization should consider price, location, rating, and outcomes to control costs while improving outcomes and satisfaction.
In addition, an intuitive referral management solution can help an organization monitor the time it takes for beneficiaries or patients to obtain an appointment or if there has been a change in the provider practice in order to expand its preferred provider network as demand increases.
Continuously check and update provider information
Accurate provider data is critical in referral management. Inaccuracies are the biggest barrier to care and contribute to higher claims costs and risk. It is essential to know if a provider moves from in-network to out of network, has moved, is no longer accepting patients, has an incorrect phone number or address before making a referral.
High performing referral networks maintain access to a centralized repository of provider data to ensure referrals to the right provider. A master provider database should be designed to check, cleanse, and manage complex, dynamic data.
Centralize referral resources
With a provider network varying in specialty, geography, and quality, it is important to keep resources consolidated and centralized in an automated, digital referrals management system. A comprehensive solution should integrate claims systems and provider directory information. Intuitive referral management solutions can even prepopulate provider and claims data to simply the workflow for claims adjusters and case managers.
A high-performing provider referral process should eliminate time-consuming administrative tasks and processes to foster better consumer and beneficiary experience and reduce the cost of care.
Learn more by checking out Perspecta's provider referral management solution.
The Centers for Medicare and Medicaid Services (CMS) is requiring that Medicare Advantage organizations, Medicaid and CHIP fee-for service (FFS) programs, Medicaid managed care plans, and CHIP managed care entities make standardized information about their provider networks available through a Provider Directory API built via FHIR.
Get to know the requirements to ensure compliance.
by April Stiles...
Navigating in the sea of disparate provider data is a tumultuous, tedious, and resource reliant endeavor. With data existing in conflicting formats and fragmented attributes, and across various applications across your organization and partners, how do you efficiently transform, cleanse, standardized, and reconcile provider data? For many healthcare organizations, provider data cleansing is like commanding a paper boat at the price of a luxury cruise ship.
The variations in formats, exchange, content, and intended use create a tsunami of costs related to internal resources, time-consuming workflows, and regulatory fines. This poses unnecessary obstacles for consumers. providers, health plans, and partners who need access to reliable provider information.
So how do you chart a better course?
Benchmark data accuracy
Before starting your data cleansing voyage, it is important to benchmark the current state of your provider information. Begin by creating a data repository that collects and maps data elements. Use a smart analytics solution that can identify and score your provider network data to pinpoint inconsistencies, duplicates, and errors.
Find an expert provider data profiler
With no industry-standard format requirement, provider data discrepancy detection becomes difficult. An AI-enabled data profiling process can automate the identification of metadata and provide visibility and data matching right down to the single attribute level. Artificial Intelligence helps to pinpoint inconsistencies to assure comprehensive data cleansing. It optimizes the cleansing process by mapping data from source to transformation and finally to destination using commonly used formats
Check. Cleanse. Check again.
Your cleansing workflow should include quality checks of the information flow to monitor and correct errors that may occur during processing. Data integrity can be ensured with AI-powered data transformation, scrubbing, validation, and transport. A final check and scoring of your data help you establish a higher benchmark for accuracy moving forward.
Don't go it alone.
Provider data is a critical part of your business, so it is important to find a partner that really knows the industry to control costs and manage the challenges you face. A trusted provider data expert can more efficiently and effectively take on the workload, helping you reduce costs and free up internal resources to focus on other areas of your business.
The goal is to reduce costs by automating workflow to continuously clean enterprise data that can be accessed for consumer searches, integration, reporting, and analyses across your organization and regulatory environment.
The value of accurate and compliant provider network data cannot be overstated. Provider Directories serve as road maps to help consumers and their families decide which health plan to enroll in or how to access care the best care for their needs. According to a 2013 Health Reform Monitoring Survey, almost 56 percent of consumers consider a health plan’s provider network to be a very important factor when selecting a health insurance plan.
Data accuracy is not only essential to assist consumer decision-making but it is also an important way for health plans and healthcare organizations to control costs and reduce network leakage. The cost is further compounded by fines from Centers for Medicare and Medicaid Services (CMS) and other government agency reaching as high as $25,000 per beneficiary for data errors.
So how do healthcare organizations manage the overwhelming amount of ever-changing provider information?
Here are 5 ways to optimize your provider network data for better consumer experience and accuracy compliance.
Simplify provider data management
In addition to consumers, provider network data is critical information necessary for team members throughout your organization. Disparities result from the use of spreadsheets, paper documents, and multiple technology systems. If one person makes an update to their spreadsheet, it may not get shared with colleagues across the organization. If everyone is working off their own data sources, the potential for manual errors, duplicates, outdated information, and other inaccuracies increases exponentially. Provider roster management becomes complicated and endless.
Outsourcing is the answer.
External hosting and management Provider directory data hosting and roster management can not only reduce workload, improve accuracy and lessen frustration, it can bring significant return on investment (ROI). By outsource the hosting and provider roster management to a trusted partner, health care organizations benefit from better data governance, more accurate payments to providers, reduced compliance risk, and happy consumers, members, and beneficiaries.
Always access "authoritative" data
It is essential that provider directories reflect the most current and accurate information about participating providers and facilities so that individuals can maximize the value of their coverage, and better enable them to make informed healthcare decisions.
A master provider data index is the solution.
An effective index process is designed for ongoing lifecycle management of provider data. This data authority should check against its own provider information, as well as third party sources. The process design considers user needs, continuously checks correctness, enables accessibility, ensures availability and keeps data fresh.
Know your provider data score
Provider data management is an ongoing process of collecting information, analyzing data, discussing with stakeholders, and sharing with partners and governing entities. It is essential to regularly update, correct, validate, and sync data. With data continuously fluctuating, it is difficult to know were to start.
A data scorecard is a great, multi-tasking solution.
Chat with consumers
Choosing the right provider is a big decision for healthcare consumers. It can become overwhelming. Even with the most intuitively designed provider directory, they may still have questions and require guidance to make the best care decisions.
Why not add online chat capabilities to your provider directory?
An AI-enable healthcare chat bot can help to guide customers through the selection process. This eliminates the need to have 24/7 staff coverage of online chat. With prepopulated and configurable Q&As, an automated chat solution can help to answer questions like "Is my primary care physician or specialist in the health plan’s network?" "Which in network hospital is closest to where I live?"
A friendly, intuitive online chat bot can help to reduce organization workload, and increase consumer confidence for a better experience with your organization.
Get member/consumer feedback
If a consumer or beneficiary has a bad experience due to inaccurate provider information or a negative provider interaction, it is important for you to know about it. Having to navigate through an automated phone system to find the right team member to address this only adds to their frustration. As you know, when a consumer has a unfortunate experience it reflects on your organization.
Solve this challenge by enabling provider rating and a directory feedback solution.
These two online solutions help to Increase customer engagement and gain provider insights. If a consumer has fresh information on changes with a provider or a negative experience, make information sharing easier. Feedback and provider ratings are a great way to enhance beneficiary and consumer communication and satisfaction.
Provider data management doesn't have to be daunting. Connect with the experts at Perspecta to understand how to improve your process. We'd love to hear from you.