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Monthly Provider Directory Insight Roundtable February, 2017
| Date post: | 13-Apr-2017 |
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Monthly Provider Directory Insight RoundtableFebruary, 2017
Webinar Agenda
1.Insider Tips: Outreach Performance Best Practices
2.Preliminary Results on AHIP pilot NORC report 3.DMHC/CDI Guidance Review for CA Health
Plans from AHIP’s Sunshine Moore4.Simon Haeder (University of West Virginia)5.Questions
Why Provider Data is Difficult to Get RightWhen a provider last moved their practice or updated their information they may not have notified every health plan, licensing board, professional society, government agency, consumer website, etc.
Old and inaccurate information is in many places leading to ongoing inaccuracies and conflicting information that is difficult to resolve.
Our Data Validation System keeps provider directories up-to-date to satisfy: Medicare Advantage Standards | Exchange & Marketplace | Medicaid Managed Care | MC Network
Adequacy Model
BetterDoctor Data Validation System
Insider Tips: Outreach Performance
Best Practices
• It’s hard to find the right person to talk to• People are afraid (Practice managers, practitioners themselves)
• People are (really really really) annoyed. • People don’t trust health plans (or contractors)
Why is it so hard to get good provider data?
This process can be overwhelming and puts the provider at risk of
noncompliance with SB-137
Regulation Mandates Each Health Plan Perform Outreach to Each Practitioner and Medical Group
Phone $$$
Fax $
Email $
Post $$$
Over time, our goal is to drive folks to update via intuitive, inexpensive and quick outreach methods - namely fax and
email.
We try to respect people’s communication preferences as much as possible.
Outreach Methods
Custom build call center tools operated by our team in Philippines
What do agents do?• Confirm + update information over the phone
• Update information from a voicemail recording
• Leave voicemails with an access token (think fax)
• Calling to deliver a token over the phone
Phone Call Validation
Fax to Online Form Validation
Deliver Token via Fax Input Token on BetterDoctor Online Portal Validate your data
Email Link to Online Form Validation
Validate your dataEmail to with secure link
Postal Mail to Online Form Validation
Deliver Token via mail Input Token on BetterDoctor Online Portal Validate your data
Good for Practice Managers:• Positive reinforcement• “Public” record of work
Good for Health Plans• Enhances Legitimacy• Establish a place to edit their data• Eases customer support
Email Validation Receipts (coming in Q1/2017)
Problem: Behavioral Health Providers & voicemail only numbers are difficult to validate information. Solution: Leave a voicemail with an access token to direct them to online form. Condition: Only leave token if provider is confirmed in voicemail.
What does the test look like?
Total Calls Made 2,691
Total Calls w/ Successful Token Delivery 941
Validation From Token Delivery (Conversion Rate) 13.6%
2nd Call Voice Mail Reminders 24%
Average Call Length 2 min 40 sec
Smart Testing: Unreachable Behavioral Health Providers without Front Desk Staff
• Single outreach reminder / ask
• Low impact on practice• Direct communication with
most authoritative / appropriate person
• Slowly move providers to lower-cost validation methods (preferably email)
• Provide best-in-class customer support and evolve our tools to manage tricky situations well.
Outreach User Testing Goals
Preliminary Results on AHIP pilot NORC report
1. Improve the accuracy of provider directories to benefit consumers regardless of whether they are covered by private insurance or public programs such as Medicare and Medicaid;
2. Reduce the number of provider calls and contacts and develop a more efficient approach for providers to update their information for ALL plans; and
3. Test different approaches to identify the most effective path to a potential solution at a national level.
Pilot Objectives
Demonstrated Improvement
In Contrast to Availity
Data Validation Vendor Availity BetterDoctor
Total Number of Providers Outreached
51,07 109,850
Percentage Providers Validated within Pilot
18.6% 47.5%
CA SB-137 Compliance Rate
N/A 18.4%
Compliance Rate - % of Outreach Satisfied
100 99.8
Outcomes BetterDoctor Vs. Availity
Outreach Methods BetterDoctor Availity
Online Portal
Phone Outreach
Fax to Online Form
Voicemail
Data Validation Outreach Methods
DMHC/CDI Guidance Review for CA Health
Plans from AHIP’s Sunshine Moore
SB 137 Uniform Provider Directory Standards
Sunshine Moore, Regional Director, State [email protected] ∙ 916.996.2376
About AHIPAmerica’s Health Insurance Plans (AHIP) is the national association whose members provide insurance coverage for health care and related services. Through these offerings, we improve and protect the health and financial security of consumers, families, businesses, communities and the nation. We are committed to market-based solutions and public-private partnerships that improve affordability, value, access and well-being for consumers.
Accident & Health Business Markets represented by AHIP in the United States:
• Major Medical• Medicaid• Medicare Advantage• Medicare Supplemental
Insurance (Medigap)• Supplemental Health• Long-Term Care• Disability Income
Insurance• Dental• Vision
• SB 137 Overview• DMHC Timeline• Summary of DMHC Uniform Provider Directory
Standards • Comparison to CDI Uniform Standards
Outline
Overview of SB 137• Must be accessible without restrictions (online and print)• Must be updated weekly• Plans must investigate potential inaccuracies via phone, email,
hyperlink• Plans must conduct annual reviews• Plans must maintain an online interface for providers to
verify/update their information• Providers must verify/update their information (“shared
responsibility”)• Enrollees are entitled to reasonably rely upon information in a
plan’s directory
Uniform Provider Directory Standards (12/30/16)• Definitions
o Contact information: telephone numbero Provider name: professional CA license; name on certification of
national entity; name identified by providero NPI number is Type 1 for individual providers, Type 2 for facilitieso Network & Network Tier (next slide)o Practice address means USPS convention where services are
rendered, may exclude if services provided in patient’s home or via telehealth, then indicate
o Product (next slide)o Languages clarified to include ASLo Provider groups as defined in statute
Naming Standards• Product Nameso Type (HMO, EPO, PPO) and whether plan is an HDHPo Metal level, if applicableo Additional information or unique identifiers permitted as long as
consistent in marketing, member communications, ID cards, provider communications and network reporting.
• Network Nameso Plan-specific name permitted as long as used consistently
across marketing and communications listed above. o Tiered networks must include the term “tiered.”
Panel Status• DMHC: “either/or” (may use more than one as long as not
conflicting) vs. CDI: “at least one of the following”o Accepting new patientso Accepting existing patientso Available by referral onlyo Available only through hospital/facilityo Not accepting new patients
• If providers panel status consistent across all products, single description is okay. If varies by product, must indicate for each product.
• If provider associated with specific tiers, must indicate and explain differences between tiers.
Flexible Standards• Email address shall be displayed but only if provider has given
written permission and has verified regularly checked, used for that purpose, and complies with health privacy
• Additional provider names may be listed• Only one NPI per provider is required• May link to another directory if meets the requirements under
SB 137 and if specifies to which products/networks the directly applies
• Not required but encouraged to provide link to provider website and description of accommodations for disabilities, if applicable
• DMHC/CDI: may vs. shall omit certain providers upon written submission of signed statement
Facilities• Name (license and may use preferred name)• Type• Address (USPS)• Contact (phone number)• NPI number• CA license number• Network tier, if applicable
Display & Search Functionality• Date last updated• Telephone, email, form for reporting
inaccuracies• Information about member complaints if
reasonably relied upon directory information• Must be searchable by any combination of:
product, provider name, provider type, zip code
o If preferred/multiple names used, must return results for same provider under all name searches.
Review of DMHC vs. CDI Uniform Standards• Slight variations in product definitions – may
not result in material differences in application of standards
• Panel status: “either/or” vs. “at least one of the following” – similar application as long as not conflicting
• May vs. shall omit providers who submit signed statement
Questions?
Thank you!
Sunshine MooreRegional Director, State Affairs
Simon HaederUniversity of West
Virginia
Provider Networks Where Are We Now and Where Are We Headed under the Trump Administration?
Simon F. HaederAssistant Professor John D. Rockefeller IV School of Policy & PoliticsDepartment of Political ScienceWest Virginia [email protected] @simonfhaeder
Overview My Previous WorkMajor Issues
Network AccuracyNetwork AdequacyOut-of-network/Surprise Billing
Future under the Trump Administration
Before We StartMajor uncertainty with to everything healthcare-relatedConcerns about civil service exodus and quality of regulations
General TrendsMoving towards narrower networksHigher out-of-pocket costsIncreasing role of government payersFiscal limitationsIncreasing regulatory variation despite ACA
Previous WorkHaeder, Simon F., David L. Weimer, and Dana B. Mukamel. 2016. “California Secret Shoppers Find Access To Physicians And Network Accuracy Are Lacking For Those In Marketplace And Commercial Plans .” Health Affairs 35(7): 1160-1166Haeder, Simon F., David L. Weimer, and Dana B. Mukamel. 2015. "Network Adequacy Standards and Health Insurance." JAMA: The Journal of the American Medical Association 314(22):2414-2415.Haeder, Simon F., David L. Weimer, and Dana B. Mukamel. 2015. “California Marketplace Hospital Networks Are Narrower Than Commercial Plans, But Access And Quality Are Comparable.” Health Affairs 34(5): 741–748.Haeder, Simon F., David L. Weimer, and Dana B. Mukamel. 2015. “Narrow Networks and the Affordable Care Act.” JAMA: The Journal of the American Medical Association 314(7): 669-670.
Directory Accuracy
Where We AreNumerous studies have shown significant problems
Study: Haeder et al (2016), CaliforniaBlue Cross and Blue Shield in 5 marketplace regions
70% inaccurateNo such provider: 10%Wrong specialty: 30%Unable to reach: 20%No new patients: 10%Insurance not accepted: 1-4%Wait times: 10-20 days
Acute conditions problematicVariation across regions but no substantive differences inside & outside marketplace
Haeder, Simon F., David L. Weimer, and Dana B. Mukamel. 2016. "Secret Shoppers Find Access To Providers And Network Accuracy Lacking For Those In Marketplace And Commercial Plans." Health Affairs 35 (7):1160-6.
Study: Georgian’s for a Healthy Future
Six plans by 3 major carriers Three-quarters of the listings had at least one inaccuracy One in five health care providers listed were not in network Fifteen percent of telephone numbers were inaccurate or inoperable thirteen percent were not accepting new patients
CMS Medicare Advantage Study
CMS study of 54 insurersCMS warned 21 Medicare Advantage32 companies with less serious mistakes5,832 doctors listed had incorrect informationmost error-prone listings involved doctors with multiple officesPiedmont Community Health Plan
errors in the listings of 87 of 108 doctors
WellCare plan in IllinoisHealth’s ConnectiCare
Could lead to penalties up to $25,000 a day per beneficiary or bans Investigation continues thru 2018 for all 300 insurers
HHS OIG Report (2014), Medicaid
1,800 providers listed, more than 200 insurers in 32 statesmore than one-third of providers couldn't be found at their location listed50 percent of providers couldn't offer appointments to Medicaid members
8 percent participated in Medicaid but weren't accepting new patients8 percent said they don't take the insurance
median wait times of two weeksMore than 25 percent had wait times of more than one month10 percent had wait times exceeding two months
Where We AreFederal action (Medicare Advantage, Medicaid, marketplaces)
CMS rules on adequacy and accuracy on marketplaces and Medicare AdvantageCMS penalties for inaccuracies
$100 per day per individual adversely affected by a non-compliant QHP or dental plan up to $25,000 per day per Medicare Advantage beneficiary
StatesLarge number have moved to address adequacyVariation by health plan type and severityCalifornia: SB 137Limitations
Directory Adequacy
Where We Are Concerns about Adequacy
Not new: Managed Care in the 1990sACA Marketplaces
Hospitals: 19 Covered California pricing regions, Blue Cross, Blue Shield, Health Net Marketplace networks are generally narrowerGeographic access similar—more limited choicesQuality equal or better
Specialty Care: 34 states with federal marketplaces 2015, 135 plansobstetrics/gynecology, dermatology, cardiology, psychiatry, oncology, neurology, endocrinology, rheumatology, and pulmonology50 and 100 miles radius18 or 19 plans deficientHigh out-of-network costs
Generally: narrower than commercial plans
Where We Are Medicare Advantage & Medicaid Managed Care
adequacy standards are usually based on the numbers of hospitals, physicians, and consumers, or consumer travel time or distance
CMS generally defers to statesNational Association of Insurance Commissioners (NAIC) Model #74Number of states have taken action
Out-of-Network/Surprise/Balance Billing
Where We Are Large number of studies have show problems
51 percent of ambulance rides potentially resulted in a balance bill in 201470% of consumers with unaffordable out-of-network medical bills did not know the healthcare provider was out-of-network at the time they received care30 % of individuals with private health insurance reported receiving an unexpected medical bill in the past two years
Nationwide chance of receiving a balance bill after in-patient visit was 20 % People in Texas were more likely to face unexpected bills: 34 percent chance Patients who received medical care in McAllen, Texas, had an 89 percent chance of receiving a surprise medical bill compared to a rate of nearly 0 percent in Boulder, Colo.
Variation by provider specialtyAnesthesiologists: highest average rates at 5.8 times Medicare rateInterventional radiology (4.5), emergency medicine (4.0), pathology (4.0), neurosurgery (4.0) and diagnostic radiology (3.8)
Narrow Networks add urgency
Where We AreFederal Level
Federal limited balance billing in Medicare (e.g. Medicare QMBs, Medicare Advantage)CMS wants states to address the issue particular wrt marketplacesSen. Bill Nelson, D-Fla., asked the Federal Trade Commission to look into surprise medical bills in emergency room situationsEnd Surprise Billing Act introduced by Rep. Lloyd Doggett, D-Texas
In the StatesAbout one-fourth of all states have policies to address at least some of the scenariosStates are moving to limit balance billing
Introduced in Rhode Island, Washington, Oregon, MontanaPassed in Florida, California, Maryland, New Mexico, New York, and Texas
What the Future Holds
At the Federal LevelRepealing the ACA
Partially?Wholly?Replacement?
Reversing regulations and regulatory guidancesCongressional Review ActHow far back?
Future regulatory actions2 for 1?
HHS & Tom PriceIn 2011 Tom Price introduced legislation designed to allow Medicare physicians to contract with patients for a set fee, then balance bill patients for any outstanding fees after Medicare submitted reimbursement.Price wants the doctor in control and getting paid from insurers with fewer hurdles or questions askedPrice and the Georgia doctors have been aggressively opposed to narrow networksAllow doctors to collectively bargain with health insurance companies over balance billing
In the StatesDepends to a degree on federal action/in-actionLimitations to state actions
MedicareMedicaid (1115 and 1332 waivers?)MarketplacesERISA
Increasing variation, bifurcation
What We Should Be Thinking AboutAccuracy as a PrerequisiteAdequacy: Moving beyond Time and DistanceAdequacy and QualityAdequacy and PriceTransparency and Consumer Choice
General TrendsMoving towards narrower networksHigher out-of-pocket costsIncreasing role of government payersFiscal limitationsIncreasing regulatory variation despite ACA
Thanks
Simon F. HaederAssistant Professor John D. Rockefeller IV School of Policy & PoliticsDepartment of Political ScienceWest Virginia [email protected] @simonfhaeder
Thank You!
