California physicians*, if you’ve heard from us, we want to hear from you! Federal and state laws require doctors to update information about themselves and their practice for each health plan with whom they contract. Failure to do so may result in penalties that range from removal from health plan directories to termination of health plan participation. This post answers frequently asked questions about provider directories, your role as physicians in keeping them updated, and how BetterDoctor can help.
*UPDATE(2018): We’re now working with health plans all over the country, not just in California but all the 50 states. If you are from the state of Washington, please check this press release about how we are helping patients in Washington to find the right doctor.
Why Are Provider Directories Important?
Provider directories typically are posted in a searchable format online and are often made available in print. Patients rely on the information in these directories to determine whether their physicians, pharmacies, or local hospitals are included in their health plan’s network. When information is missing or inaccurate, patients may be denied care or end up with unexpected medical bills.
Among providers with whom BetterDoctor has worked, physician rosters and types of insurance that providers accept may change as often as every 90 days; 20% of provider information in directories changes each year. Of Medicaid Advantage plans the federal Centers for Medicare and Medicaid Services reviewed, nearly half—45 percent—of the sample of provider directory data tested was inaccurate. It is essential that provider directories include current and accurate information about a health plan’s participating providers and facilities to comply with federal and state law and provide actionable information for patients.
How Is Provider Directory Information Updated?
Currently, there is a patchwork of efforts among health plans and providers to ensure that information in provider directories is up to date and accurate, and challenges abound. Information can become quickly out of date when, for example, doctors stop accepting new patients or change their office hours. Physicians often contract with multiple health plans or medical groups, each of which may have different means of validating provider information. A study by America’s Health Insurance Plans (AHIP) reveals that physicians frequently are unaware of the need to proactively alert health plans to changes in their information or do not understand the need to respond to plan requests about this data.
What Is My Role as a Physician in Updating My Information?
We’re glad you asked! Both federal and state laws require that health plans maintain accurate, up-to-date provider directories. Health plans participating in Medicare Advantage are required to reach out to providers quarterly. Under California law, SB-137, health plans must contact providers at least once every six months.
More important, however, SB-137 also includes requirements for providers.
- Providers must notify plans and insurers within five business days if they are no longer accepting new patients, or if they previously were not accepting new patients and are now open to seeing them.
- Providers must respond to plan and insurer requests to validate their information by either confirming that the information is correct or by updating it.
- Failure to respond to such requests may result in delayed payment, removal from the provider directory, or termination of the provider’s contract.
What Is BetterDoctor’s Role in Updating Provider Directories?
BetterDoctor delivers accurate provider directory data to ensure that health plans, health systems, provider groups, and doctors comply with all federal and state regulations and provide patients with access to timely, appropriate medical care. In 2016, BetterDoctor participated in a pilot program conducted by AHIP to test different approaches to improving the accuracy of provider directories in three states—California, Florida, and Indiana. You can read key findings of the study in BetterDoctor’s free white paper, The challenges behind fixing provider directory data.
Of note, BetterDoctor’s multimodal outreach approach—which includes phone calls, faxes, emails, and alerts within online portals—proved effective. Of the nearly 110,00 providers BetterDoctor reached, 48 percent responded to at least a partial set of validation questions and 18 percent responded to a full set of questions.
It took providers, on average, 16 minutes to use BetterDoctor’s online validation form and 4 minutes to complete their update by phone. BetterDoctor continues to work with four AHIP member plans—Humana, Western Health Advantage, Care More, and Health Net—to validate and update their provider directories.
If you participate in one of these plans, you may receive a request from us to update your information. However, you should also expect other health plans that are not affiliated with our efforts to reach out to you. Please respond to all verification requests from all vendors or health plans.
How Does BetterDoctor’s Validation Process Work?
BetterDoctor makes life easy for health plans and their physicians. Here’s how we work:
- Health plans share their doctor data with BetterDoctor.
- BetterDoctor validates the data and proactively contacts you.
- We will try to reach you by phone, fax, email, and through existing online portals. Our goal is to use the method most convenient for you.
- We will give you a unique key to access our online validation system, which is easy to use and fast to complete.
- Validated doctor data is pushed back in real time to health plans.
- BetterDoctor notifies health plans of validated changes.
Among the key findings of the AHIP study was that: “Maintaining accurate provider directories is a shared responsibility that requires a joint commitment from health plans and providers to ensure consumers and patients have the information they need and the information is updated in a timely and accurate fashion.”
BetterDoctor works to help doctors and health plans honor this commitment, and the patients they serve are the ultimate beneficiaries.
To learn more, or with questions about a verification request you receive from us, contact us today at email@example.com. We look forward to working with you!
If you want to learn more about our data validation services, visit our website and download our White Paper on The Challenges behind fixing provider directory data.