April 13, 2016
Area(s) of Interest: Practice Management
On July 1, 2016, a new law will take effect that requires plans to ensure that 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.
To accomplish this, payors are required to contact providers in writing, electronically and by telephone. The payor must document the outcome of each attempt. If the payor is unable to verify the provider’s information, it may remove the provider from the directory and delay payment, but must first provide at least 10 business days advance notice.
The California Medical Association will be hosting a webinar about the new law and a directory accuracy pilot program on Wednesday, April 27. The webinar will provide an overview of the pilot program, launched by Americas Health Insurance Plans, and the requirements of SB 137, including its effect on physician practices. The webinar will also go over what to expect in terms of outreach and the information requested by the program vendor. To register, click here.
Under the new law, plans and insurers will be required to have certain data fields in the directory including, but not limited to, provider name, specialty, board certification (if any), practice address, city, zip, license number, NPI, whether the provider is accepting new patients, the product and/or tier, and admitting privileges to hospitals contracted with the plan/insurer.
Directories must include also include an email address and telephone number to which inaccuracies can be reported. The payors must then promptly investigate and correct any issues within 30 business days.
Physician obligations under SB 137
The new law also requires physicians to do their part in keeping the 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 provider to direct the patient to the plan/insurer to find a provider or to the regulator to report a directory inaccuracy.
SB 137 requires physicians 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 provider group may terminate a contract with a provider for a pattern or repeated failure to update the required information in the directories.
Contact: CMA's reimbursement help line, (888) 401-5911 or firstname.lastname@example.org.