BetterDoctor’s monthly webinar series on provider directory best practices and regulation guidance. Join the discussion alongside health plans, provider groups, policy makers, and industry experts.

1. Monthly Provider Directory
Insight Roundtable
February, 2017

2. 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 Moore
4.Simon Haeder (University of West Virginia)
5.Questions

3. Why Provider Data is Difficult
to Get Right
When 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.

4. 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

5. Insider Tips:
Outreach Performance
Best Practices

6. • 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?

7. 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

8. 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

9. 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

10. Fax to Online Form Validation
Deliver Token via Fax Input Token on BetterDoctor Online Portal Validate your data

11. Email Link to Online Form Validation
Validate your dataEmail to with secure link

12. Postal Mail to Online Form Validation
Deliver Token via mail Input Token on BetterDoctor Online Portal Validate your data

13. 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)

14. 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

15. • 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

16. Preliminary Results on
AHIP pilot NORC report

18. 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

19. Demonstrated Improvement

20. In Contrast to Availity

21. 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

22. Outreach Methods BetterDoctor Availity
Online Portal
Phone Outreach
Fax to Online Form
Email
Mail
Voicemail
Data Validation Outreach Methods

23. DMHC/CDI Guidance
Review for CA Health
Plans from AHIP’s
Sunshine Moore

24. SB 137 Uniform Provider Directory
Standards
Sunshine Moore, Regional Director, State Affairs
smoore@ahip.org ∙ 916.996.2376

25. About AHIP
America’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

26. • SB 137 Overview
• DMHC Timeline
• Summary of DMHC Uniform Provider Directory
Standards
• Comparison to CDI Uniform Standards
Outline

27. 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

29. Uniform Provider Directory Standards
(12/30/16)• Definitions
o Contact information: telephone number
o Provider name: professional CA license; name on certification of national
entity; name identified by provider
o NPI number is Type 1 for individual providers, Type 2 for facilities
o 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 ASL
o Provider groups as defined in statute

30. Naming Standards
• Product Names
o Type (HMO, EPO, PPO) and whether plan is an HDHP
o Metal level, if applicable
o Additional information or unique identifiers permitted as long as
consistent in marketing, member communications, ID cards, provider
communications and network reporting.
• Network Names
o Plan-specific name permitted as long as used consistently across
marketing and communications listed above.
o Tiered networks must include the term “tiered.”

31. 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 patients
o Accepting existing patients
o Available by referral only
o Available only through hospital/facility
o 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.

32. 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

33. Facilities
• Name (license and may use preferred name)
• Type
• Address (USPS)
• Contact (phone number)
• NPI number
• CA license number
• Network tier, if applicable

34. 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.

35. 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

36. Questions?
Thank you!
Sunshine Moore
Regional Director, State Affairs
smoore@ahip.org
916-996-2376
mosman@ahip.org

37. Simon Haeder
University of West
Virginia

39. Provider Networks
Where Are We Now and Where Are We Headed under the
Trump Administration?
Simon F. Haeder
Assistant Professor
John D. Rockefeller IV School of Policy & Politics
Department of Political Science
West Virginia University
Simon.Haeder@mail.wvu.edu
@simonfhaeder

40. Overview
My Previous Work
Major Issues
Network Accuracy
Network Adequacy
Out-of-network/Surprise Billing
Future under the Trump Administration

41. Before We Start
Major uncertainty with to everything healthcare-
related
Concerns about civil service exodus and quality of
regulations

42. General Trends
Moving towards narrower networks
Higher out-of-pocket costs
Increasing role of government payers
Fiscal limitations
Increasing regulatory variation despite ACA

43. Previous Work
Haeder, 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): 1160-1166
Haeder, 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.

44. Directory Accuracy

45. Where We Are
Numerous studies have shown significant problems

46. Study: Haeder et al (2016), California
Blue Cross and Blue Shield in 5 marketplace regions
70% inaccurate
No 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 problematic
Variation 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.

47. 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

48. CMS Medicare Advantage
Study
CMS study of 54 insurers
CMS warned 21 Medicare Advantage
32 companies with less serious mistakes
5,832 doctors listed had incorrect information
most error-prone listings involved doctors with multiple offices
Piedmont Community Health Plan
errors in the listings of 87 of 108 doctors
WellCare plan in Illinois
Health’s ConnectiCare
Could lead to penalties up to $25,000 a day per beneficiary or bans
Investigation continues thru 2018 for all 300 insurers

49. HHS OIG Report (2014),
Medicaid
1,800 providers listed, more than 200 insurers in 32 states
more than one-third of providers couldn't be found at their
location listed
50 percent of providers couldn't offer appointments to Medicaid
members
8 percent participated in Medicaid but weren't accepting new patients
8 percent said they don't take the insurance
median wait times of two weeks
More than 25 percent had wait times of more than one month
10 percent had wait times exceeding two months

50. Where We Are
Federal action (Medicare Advantage, Medicaid, marketplaces)
CMS rules on adequacy and accuracy on marketplaces and Medicare
Advantage
CMS 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
States
Large number have moved to address adequacy
Variation by health plan type and severity
California: SB 137
Limitations

51. Directory Adequacy

52. Where We Are
Concerns about Adequacy
Not new: Managed Care in the 1990s
ACA Marketplaces
Hospitals: 19 Covered California pricing regions, Blue Cross, Blue Shield, Health Net
Marketplace networks are generally narrower
Geographic access similar—more limited choices
Quality equal or better
Specialty Care: 34 states with federal marketplaces 2015, 135 plans
obstetrics/gynecology, dermatology, cardiology, psychiatry, oncology, neurology,
endocrinology, rheumatology, and pulmonology
50 and 100 miles radius
18 or 19 plans deficient
High out-of-network costs
Generally: narrower than commercial plans

53. 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 states
National Association of Insurance Commissioners
(NAIC) Model #74
Number of states have taken action

54. Out-of-
Network/Surprise/Balan
ce Billing

55. Where We Are
Large number of studies have show problems
51 percent of ambulance rides potentially resulted in a balance bill in 2014
70% of consumers with unaffordable out-of-network medical bills did not know the
healthcare provider was out-of-network at the time they received care
30 % 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 specialty
Anesthesiologists: highest average rates at 5.8 times Medicare rate
Interventional radiology (4.5), emergency medicine (4.0), pathology (4.0), neurosurgery (4.0) and
diagnostic radiology (3.8)
Narrow Networks add urgency

56. Where We Are
Federal Level
Federal limited balance billing in Medicare (e.g. Medicare QMBs, Medicare
Advantage)
CMS wants states to address the issue particular wrt marketplaces
Sen. Bill Nelson, D-Fla., asked the Federal Trade Commission to look into
surprise medical bills in emergency room situations
End Surprise Billing Act introduced by Rep. Lloyd Doggett, D-Texas
In the States
About one-fourth of all states have policies to address at least some of the
scenarios
States are moving to limit balance billing
Introduced in Rhode Island, Washington, Oregon, Montana
Passed in Florida, California, Maryland, New Mexico, New York, and Texas

57. What the Future Holds

58. At the Federal Level
Repealing the ACA
Partially?
Wholly?
Replacement?
Reversing regulations and regulatory guidances
Congressional Review Act
How far back?
Future regulatory actions
2 for 1?

59. HHS & Tom Price
In 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 asked
Price and the Georgia doctors have been aggressively
opposed to narrow networks
Allow doctors to collectively bargain with health insurance
companies over balance billing

60. In the States
Depends to a degree on federal action/in-action
Limitations to state actions
Medicare
Medicaid (1115 and 1332 waivers?)
Marketplaces
ERISA
Increasing variation, bifurcation

61. What We Should Be Thinking
About
Accuracy as a Prerequisite
Adequacy: Moving beyond Time and Distance
Adequacy and Quality
Adequacy and Price
Transparency and Consumer Choice

62. General Trends
Moving towards narrower networks
Higher out-of-pocket costs
Increasing role of government payers
Fiscal limitations
Increasing regulatory variation despite ACA

63. Thanks
Simon F. Haeder
Assistant Professor
John D. Rockefeller IV School of Policy & Politics
Department of Political Science
West Virginia University
Simon.Haeder@mail.wvu.edu
@simonfhaeder

64. Thank You!