December 02, 2015
On July 1, 2016, a new law will take effect that requires plans and insurers to comply with uniform standards, and provide timely updates, for their provider directories. The law (SB 137) includes multiple components aimed at providing patients with more accurate and complete information to identify which providers are in their payor’s network.
Specifically, the law requires:
- Plans/insurers must offer an online provider directory available to the public, including physicians, without any restrictions or limitations.
- The directory must be searchable electronically by, at a minimum, name, practice address, city, zip code, license number, NPI, admitting privileges to an identified hospital, product, tier, provider language, provider group, hospital name, facility name, or clinic name, as appropriate. This provision takes effect July 31, 2017, or 12 months after the date provider directory standards are developed, whichever occurs later.
- The directory must use a consistent method of network naming, product naming, or other classification method to ensure easy identification of which providers participate in which networks for which products. This provision is effective July 31, 2017, or 12 months after the date provider directory standards are developed, whichever occurs later.
- The directory must state whether a provider is accepting new patients.
- The directory must include an email address and telephone number for providers and members of the public to report directory inaccuracies.
- The directory must not include providers who do not have a current contract with the plan/insurer. If a provider is listed as participating in error and an enrollee reasonably relied upon that information, the plan/insurer may be required to pay for covered services and to reimburse the enrollee for any amount beyond in-network cost sharing.
- Plans/insurers must promptly investigate, and, if necessary, correct any issues within 30 business days if they receive a report of a possible inaccuracy in the directory.
- Plans/insurers must update paper directories at least quarterly and online directories at least weekly.
- Plans/insurers must file an amendment with the regulator if there is a 10 percent change in the network size for a product in a region.
- Plans/insurers must include a contractual requirement that providers inform the plan within five business days if they are not accepting new patients or if they were previously not accepting new patients but are now open to new patients.
- Plans/insurers must have a process to ensure accuracy, and must at least once per year conduct a thorough review and update of the directory. This process must include notification to contracting providers to advise them of the information the plan has about them in the directory. Group providers will be noticed annually and other providers will be noticed every six months. The notice must include information about how providers can update their directory information using an online interface, which must generate an acknowledgment of receipt by the plan. The notice must also include a statement that the failure to respond may result in a delay of payment.
- If the payor does not receive updates to any information or confirmation from the provider that the information is accurate, the plan is required to verify the provider’s information by contacting the provider in writing, electronically and by telephone. The plan must document the outcome and each attempt to verify the information. If the payor is unable to verify the provider’s information, the payor may remove the provider from the directory and delay payment, after providing at least 10 business days advance notice.
- The directory must inform enrollees of their rights to language interpreter services and access to covered services under the ADA.
SB 137 Effect on Physicians
The new law also establishes certain requirements for physicians. The requirements underscore the importance of ensuring that practice demographic information, including whether or not the practice is accepting new patients, is up-to-date with contracted payors and any changes to practice demographics are communicated to the plan/insurer in a timely manner. Specifically, the law requires:
- Providers will be required to notify plans and insurers 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, the provider must direct the patient to the plan/insurer to find a provider or to the regulator to report a directory inaccuracy.
- Providers will be required to respond to plan and insurer notifications regarding the accuracy of information in the provider directory by either confirming the information is correct or 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.
- For providers that have capitated payor contracts, the plan can delay up to 50 percent of the next scheduled capitated payment for up to one calendar month if they fail to update their provider demographics or fail to confirm the accuracy of the current information. Payments to providers who have fee-for-service contracts can be delayed for up to one calendar month, beginning on the first day of the following month.
To help physicians understanding how to update their provider demographic information, until the electronic online option is required, the California Medical Association (CMA) queried the major payors on their processes. Their responses have been compiled into a members-only resource for physicians, “Updating Provider Demographic Information with Payors,” which is available free to CMA members.