May 03, 2016
Area(s) of Interest: Payor Contracting Payor Issues and Reimbursement
On July 1, 2016, a new law will take effect that requires plans to ensure that their physician directories are accurate and up-to-date. The law (SB 137) includes multiple components aimed at providing patients with more accurate and complete information to identify which providers are in their payors' networks.
The new law also requires physicians to do their part in keeping their information up-to-date. Specifically, the law requires providers to notify payors within five business days if they are no longer accepting new patients or, alternatively, if they were previously not accepting new patients and are now open to new patients.
If a provider is not accepting new patients and is contacted by a new patient based on information found in the payor's provider directory, the new law requires the provider to direct the patient to the plan/insurer to find a provider, or to the regulator to report a directory inaccuracy.
Physicians are also required under the new law to respond to plan and insurer notifications regarding the accuracy of their provider directory information, either by confirming the information is correct or by updating demographic information as appropriate. Failure to do so may result in a delay in payment and removal from the provider directory. Additionally, a payor may terminate a contract with a provider for a pattern or repeated failure to update the required information in the directories.
Some payors have already notified physicians of the new requirements via contract amendment and/or provider manual updates. Specifically, Anthem sent out an amendment to contracted providers on March 30, while Blue Shield of California sent its notice and amendment out on April 22.
Practices are encouraged to review the amendments and/or provider manual updates closely to ensure they can comply with the requirements. When contract changes are made purely to comply with a change in the law, plans are not required to notify practices before the change takes effect. However, if there are other changes included in the amendment that are considered “material changes,” payors will be required to provide practices with 45 business days’ advance notice.
While the majority of the changes noted in the amendments will likely be regulatory in nature, practices should review the amendments closely to identify any nuances between payors. For example, SB 137 requires providers to respond to requests from payors to confirm/update provider directory information within 30 business days. However, Anthem is requiring responses within 15 business days. Additionally, while the legislation states a payor may terminate a physician or physician group contract for repeated failure to update provider directory information, Section 9 of the Anthem amendment is more specific and states practices may be terminated if they fail to respond more than twice during the term of the contract.
It will be imperative that staff responsible for phones, email and faxes are aware of the requirements and are prepared for the inquiries. It is also important that practices respond in a timely manner and are accurate in the responses given.
The California Medical Association (CMA) recently hosted a webinar, &ldquo Ensure Your Practice is Ready and Won’t Be Penalized Under the New Provider Directory Accuracy Law,” that gives an overview on the new law and a pilot program launched by America’s Health Insurance Plan. The pilot was designed to ensure physician directories are more accurate and payors are compliant with SB 137 requirements, while reducing the administrative burden for practices. This webinar is now available on demand in CMA's online resource library and is free to CMA members.
Contact: CMA's reimbursement help line, (888) 401-5911 or firstname.lastname@example.org.