“No Surprises Act” Contains New Provider Directory Verification Regulations

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Senior Solution Consultant

Surprise medical billing has long been an issue that both political parties agree needs to be addressed. At the close of 2020, congress passed HR 133 containing the “No Surprises Act” to address several contributing factors causing surprise medical bills, including provider directory accuracy.

Previously, only directories of Medicare, Medicaid, and Qualified health plans had any requirements around verification of accuracy. However, this latest bill applies to all group and individual health plans.

How This Impacts You

Similar to existing CMS directory regulations, the new act requires health plans to verify and update provider directory information at least every 90 days, which includes both individual providers and facilities. You must remove unverified providers from the directory and make updates within two days of receipt. Additionally, the bill specifies that you will be responsible for any out-of-network billing done through providers listed on the directory as in-network.

For most health plans, this will be a new or significant expansion to directory maintenance operations. Ownership is placed on both health plans and providers in this bill to work together in establishing communication channels for updates, but the ongoing verification work is the health plan’s responsibility.

The goals of the “No Surprises Act” are commendable, and it is another step toward preventing surprise medical billing and helping patients understand their medical costs and network reach before receiving care. Health plans and providers are linchpins in this process, and must continue improving methods to keep their contracts, websites, member materials and directories up to date.

Next Steps for Improving Provider Directory Information

If you don’t have a plan to meet the requirements of the new regulation, it’s a good time to start. The new rules go into effect in less than a year. If you’re not sure where to get started, visit our provider data quality page or call 1-866-396-7703.

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At LexisNexis Risk Solutions, our goal is to provide the healthcare industry with insights and innovations to improve outcomes, grow market share, reduce fraud and increase compliance.

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