new healthcare law

Health plan guidance: 3 essentials for no-surprises Act compliance

In recent years, the healthcare industry has increasingly been paying attention to the error rates in health plan directories. Undependable directories create poor member experience by impacting access to care. The Consolidated Appropriations Act COVID-19 relief bill, signed into law on December 27, 2020, requires health plans and healthcare providers to work in tandem, so that members are informed and protected.  This law, under the No Surprises Act, an interim final rule recently passed, mandates that health organizations ensure provider directories are current and accurate. Currently this Act targets an effective date of January 1, 2022, with health plans required to verify provider contract status and updates every 90 days. Health plans and organizations that do not comply face penalties and both member and provider abrasion.

As Provider Network Operations is increasingly at the fulcrum of both health plan operations and optimized consumer experience, here is how operations experts such as business process outsourcers (BPOs) can efficiently and effectively address the three aims of No Surprises:

1. Health plans need to update provider directories and respond quickly to consumers.

The No Surprises legislation requires health plans to update their database within 48 hours of receiving demographic change requests from a provider.

How BPOs Can Help: The right operations partner can provide the people, process, and technology expertise to update directories with speed and quality.This enables real-time provider demographic updates. This output can be either shared through an automated nightly batch run that updates the plan’s database directly or as an output file in any desired format. Additionally, dashboards can provide visibility and ensure compliance as well as access to data that can help drive process refinement specific to the experiences (such as, if a provider prefers phone outreach or responds to phone outreach, but does not respond to email outreach, processes can be refined based on the data we have collected based on the experiences to reduce provider abrasion). These insights go a long way toward both No Surprises compliance and the enhanced Star ratings and reduced provider abrasion that support optimized experience.

2. Regular verification of provider contract status and updates is required at least once every 90 days.

How BPOs Can Help: Provider Data Verification and Collection modules can help to conduct planned outreach campaigns to collect provider data. This data collection and verification activity can be performed outside of clients’ core systems and the application can provide cleaned output files in most industry-standard formats.

The verification aspect of network management is complex, as all providers and provider groups have different communication preferences. The right BPO partner will have customized applications, as well as multimodal outreach processes that use three different communication channels:

  • Phone
  • Email with link to online self-service portal
  • Fax

Another network management challenge is reaching out to providers without adding to their workload. Traditionally, most provider verification campaigns for updated directory information are run by fax or phone. While provider outreach can be supported via fax, phone, or email depending on what works best for a particular office, the ideal option is directing providers to an online pre-populated form. Providers can easily update their information without having to deal with pesky manual forms or spend more time over phone, and health plans receive updates quickly and efficiently.

3. Healthcare providers must communicate information more frequently to health plans to verify accurate directory information.

How BPOs Can Help: Today’s providers must respond to a constant flow of requests that taxes resources and adds to cost. Network management experts can provide tools via customized auto-reminders to the contact person at practices, alerting them that it is time to attest demographic information pertaining to their providers.

All of these No Surprises mandates are on the horizon—along with the requisite additional oversight and compliance. On the bright side, today’s healthcare organizations can seize the moment and accelerate their drive toward a more B2C healthcare experience. And BPOs have the required core solutions to get them there faster—with critical No Surprises compliance and also the solutions to meet of the ever-raised bar of optimized provider experience, accurate provider data/directory, and improved and more cost-effective processes. When accurate information is made available on consumer directories, millions of members are empowered to make the choices that are best for them and their families.

Priya Sabharwal
By Priya Sabharwal, Associate Vice President, HGS

Stacy WisnerAnd Stacy Wisner, Senior Director of the CRM Center of Excellence at HGS

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