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January 3, 2023

Outdated Insurance Provider Directories Could Force Refunds for Out-of-Network Care

The No Surprises Act aims to prevent patients from facing exorbitant and unexpected medical billing, but it’s also increased the administrative burden on health care providers and facilities due to insurance provider directory update requirements. As part of the law, health care providers or facilities who fail to reconcile these directories could be forced to refund patients who inadvertently selected out-of-network care due to inaccuracies in the provider directory and already paid their bill.  

Ensuring these directories stay up to date can be burdensome and time consuming, but it’s vital work to ensure compliance with the new law. Outsourced credentialing can free up staff’s time so they can focus instead on providing excellent patient service.  

Key Takeaways:  

  • All health care providers and facilities, no matter their category, must follow requirements surrounding provider directories, there are no exemptions 
  • Failure to update provider directories can result in refunds to patients who selected and were billed for out-of-network care, paid by the provider and/or health care facility 
  • Provider directory information must be submitted to a plan or issuer when beginning or ending a network agreement, upon material changes to the content of provider directory information, or upon request of the plan or issuer, among other triggers  

Understanding the No Surprises Act 

The No Surprises Act is a law meant to establish federal standards to reduce or otherwise end surprise medical bills for fully insured individuals, small groups, large group markets, as well as self-insured group plans that include grandfathered plans for plan and policy years beginning on and after January 1, 2022. There are three types of health care providers and facilities that this law applies to: 

  1. Out-of-network emergency services provided by a hospital or free-standing emergency facilities 
  1. Out-of-network providers at in-network facilities 
  1. Out-of-network air ambulance carriers 

The law also established an Independent Dispute Resolution (IDR) process, which is also referenced as arbitration, to resolve disputes between out-of-network providers and insurers. The IDR also prohibits balance billing by out-of-network providers, although there are certain exceptions to this rule. For instance, if a patient were to knowingly choose to receive items, services or care from an out-of-network provider, the law does not apply.  

Insurance Provider Directories Must Be Kept Up to Date 

To keep patients or plan enrollees from inadvertently selecting out-of-network care or services, provider directories must be kept updated and free of inaccuracies. Should a patient reference the directory to select a health care provider and unknowingly chooses an out-of-network provider, they could be subjected to a large, out-of-network bill.  

If they pay that bill, the patient generally becomes eligible to receive a refund of the amount paid in excess of in-network cost-sharing amounts, with interest. Under the law, providers and health care facilities would generally be responsible for providing that refund. 

By setting and maintaining rigorous business processes to submit provider directory information, health care facilities and providers can keep their provider directories accurate and up to date.  

What Information Must Be Provided to a Plan Provider Directory? 

According to the Centers for Medicare & Medicaid Services (CMS), the following information must be provided to the provider directory and verified regularly to ensure information remains accurate: 

  • Names, addresses, specialty, telephone numbers and digital contact information of individual health care providers 
  • Names, addresses, telephone numbers and digital contact information of each clinic, health care facility and medical group contracted to participate in any of the networks of the group health plan or health insurance coverage involved 

When Are Provider Directories Required to Be Updated? 

There are four basic triggers that dictate when a provider or facility must submit their provider directory information to a plan or issuer: 

  • Upon beginning a network agreement with a plan or issuer with respect to certain coverage 
  • Upon terminating a network agreement with a plan or issuer with respect to certain coverage 
  • When material changes are made to the content of provider directory information of the provider/facility 
  • Upon request of the plan or issuer, or as deemed appropriate by the provider/health care facility or the Secretary of Health and Human Services 

It should be noted that health plans are required to verify directory information at least every 90 days. While some insurances had already been verifying this information on a regular basis, others haven’t which has led to a surge in the number of overall requests. 

When your organization outsources their credentialing with Anders, we can provide full-coverage services that take a holistic approach to ensure these tedious administrative duties are handled in a timely manner to maximize your potential revenue. From gathering necessary paperwork to communicating with insurance payers to maintaining recredentialing and license renewals processes, Anders Health Care Group is the partner you can trust to handle the background work while your staff turns their focus to caring for patients.  

If your organization is struggling under a recent deluge of directory verification requests, Anders Health Care advisors and our partners at Fifth Avenue Healthcare Services can help alleviate your administrative burden and ensure seamless compliance with the No Surprises Act. Learn more about our outsourced credentialing and provider enrollment processes or contact an Anders advisor below to get started.

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