Beginning January 1, 2016, CMS will be strengthening their benchmarks for provider network data. This is due to a year plagued with consumer complaints regarding misleading provider network data in addition to CMS audits that have uncovered massive errors rates in provider directory resources. A series of high-profile health plan lawsuits have further brought attention to the inadequacy of directory data and the need for a proactive, structured process to be put in place to ensure accuracy and assess the availability of contracted providers.

Current provider network management involves a variety of disparate data systems, manually fulfilled processes and a lack of coordination across business groups. CMS has recognized plans’ inability to create a flexible and fluid structure for managing their provider networks, and has put the Provider Network Adequacy (PNA) Pilot Program in place in an effort to force plans to modernize their directory data management infrastructures and conduct continuous self-evaluations.

With the goal of monitoring and expanding beneficiary access to care, the PNA Pilot program is pushing plans to think beyond the historic crutches of disclaimers, hard-copy reprints and addendum notifications as the key means for dealing with provider network change. Instead, plans must now leverage workflow automation tools and real-time notifications as a more efficient means for keeping their data up-to-date while educating their members on how to better use technology to access provider information online. At the heart of this initiative is the reality that all too often when a provider moves out of state, changes network mid-year or closes access to new patients, it is the plan that is the last to know. So how are plans to be expected to validate the availability of their contracted providers? By implementing coordinated provider outreach communication programs that incentivize providers to want to validate their data through value-based collaboration. This two-way exchange is key to maintaining CMS network adequacy requirements and opens new doors to transforming provider relations into deeper, broader and more informative dialogue.

Recognizing that provider validation is critical, CMS dictates that Medicare Advantage organizations communicate with providers once every three months to verify contact information and whether or not they are accepting new patients and must update their directory within 30 days. While there is no specific requirement regarding provider outreach frequency for QHPs, they  must update their print directories on a monthly basis and their online directories in real-time. As far as state regulations go, however, the regulations vary drastically from state-to-state . For example, some states require updates on a monthly basis with additional provider validation requirements, while others offer no additional guidance to the federal requirements.

While the notion of auditing and rebuilding your network provider data management infrastructure may seem like a daunting task at the time, it’s potential to eliminate litigation and regulatory risk is certainly proven to be worth the investment. More importantly, CMS’s overarching goal to enhance member transparency into in-network providers and ease navigation of this data should in turn prove to support value-based reimbursement, increase patient outcomes and strengthen provider relations.