Ensuring Provider Directory Compliance With H.R. 133

By Donald Potts and Donovan Schwartz

If you have a provider directory, you probably know about the Consolidated Appropriations Act of 2021 (aka H.R. 133).

Passed last December, the Act requires group health plans and health insurance issuers to improve the verification and refresh process of their provider directory systems. The goal is to improve the accuracy and transparency of provider information for consumers and minimize the impacts of unverified data.

However, based on discussions with Verisys clients and prospects, most health plans are unprepared to meet the requirements due by January 1, 2022. That’s right: the week after next. The law asks health plans and insurers to:

• Verify and update directories at least every 90 days. “Verification” will likely require some form of audit.
• Remove providers that can’t be verified. New procedures might be required.
• Refresh provider data within two business days of receiving a request for update from providers. Regulations passed just last year for the Interoperability and Patient Access final rule mandate a 30-day refresh frequency.
• Ensure key provider attributes are verified and up to date. These include name, address, specialty, telephone, and electronic contact information.

H.R. 133 also covers several other topics related to billing and directory operations not mentioned above. For more information, see the American Medical Association’s Summary of Select Provisions.

The Act and the Final Rule are only two of the three pieces of legislation dealing with provider directories introduced in the past two years; the third is the Transparency in Coverage Final Rule.

While the three regulations combined place a strain on healthcare information technology resources, there is hope. Should a group health plan, insurer, or state agency find that time is running out on achieving regulatory compliance with H.R. 133, here are our top three recommendations:

1. Develop a flexible architecture. The faster organizations move to elastic cloud processing, parallel processing, or near-real-time business services through Application Programming Interfaces (APIs), the faster-achieving compliance will be for future regulations.
2. Participate in workgroup meetings. Joining workgroup meetings, like those held for HL7 Fast Healthcare Interoperability Resources (FHIR), will help organizations learn from other industry participants about best practices.
3. Include more perspectives. Insourced projects like provider directories often take an IT-based approach instead of a broad-industry product approach. By having open-development discussions with all stakeholders — from departments across the enterprise as well as external partners — organizations can ensure the final product aligns with the needs of all.

Since implementing these recommendations may strain your organization’s resources, partnering with an experienced industry leader in provider directories deserves consideration. Verisys brings a broader perspective to quickly address new challenges as a result of working with multiple commercial and governmental clients. Our experience in provider directories uniquely positions us to partner with healthcare organizations to solve problems, like H.R. 133’s two-business-day refresh rate. Our clients benefit from this partnership by freeing up time to focus on other priorities.

Contact us today to find out how we can help prepare you for the quickly approaching changes in 2022.

–Donald Potts has helped healthcare customers define business problems and design innovative solutions since he started at Optum in 2008. Now as vice president of enterprise strategic accounts at Verisys, he focuses primarily on large payers and government agencies requiring a quick turnaround driven by compliance, or merger and acquisition issues. Prior to entering the healthcare industry, he worked for several technology companies. Donald has a B.S. in electrical engineering from Fairleigh Dickinson University, and executive master certificates in computer science and business administration.

–Donovan Schwartz has worked in provider and payer data technology solutions for the past seven years. He leads teams with a specific focus on network management, provider master data management, and directory services. As a product manager at the healthcare technology and services company Verisys, he guides many of the solutions that support health plans, health systems, and state Medicare and Medicaid agencies. Prior to coming to Verisys, he developed innovative healthcare solutions to improve quality and effectiveness for payers and members at Optum.