You can learn a lot from first graders, especially if those first graders were drawn by the ever-comforting hand of the late Charles Schultz. If there’s one thing we learned from Charlie Brown for decades of the comic strip, Peanuts, it is never to trust Lucy with a football.
You know the story–good old Charlie is on a never-ending quest to kick a football but is repeatedly duped by Lucy, as she yanks it away at the last moment. It’s funny in simple line drawings, but we can all relate to the feeling of disappointment and frustration Charlie experiences when he spins head over heels yet again.
If your members have searched for a provider on your network directory, found a good fit, and then found that they were no longer in-network, they really understand this feeling. That’s why more states are instituting stricter regulations to eliminate ghost networks and ensure provider data accuracy throughout the plan year. Recent changes in California regulations mean that insurance companies need extra vigilance to root out ghost networks and ensure their members aren’t getting the football snatched away.
California's Rules for the Game
Ghost networks are the primary target of CA Senate Bill 137, codified as CA HSC 1367.27. To this end, the regulation requires all full-service health insurance plans and specialized mental health plans to include, but not limited to, the following information in their provider directories:
- Provider’s name, practice location or locations, and contact information.
- Provider’s office email, if available.
- Type of practitioner (MD, NP, DO, etc.)
- National Provider Identifier number (NPI)
- California license number and type of license.
- The area of specialty, including board certification, if any.
- The name of each affiliated provider group currently under contract with the plan through which the provider sees enrollees.
- Non-English language, if any, spoken by a health care provider or other medical professional as well as non-English language spoken by a qualified medical interpreter, in accordance with Section 1367.04, if any, on the provider’s staff.
- Identification of providers who no longer accept new patients for some or all of the plan’s products.
- The network tier to which the provider is assigned, if the provider is not in the lowest tier, as applicable. Nothing in this section shall be construed to require the use of network tiers other than contract and noncontracting tiers.
- For the complete list, refer to CA HSC 1367.27.
On the surface, this may seem like a manageable task, but the reality is far from it. Keeping track of updating provider information can be daunting and time-consuming, especially when done manually.
Fortunately, Quest Enterprise Services (QES) has developed a solution to this problem. With its advanced technology and expertise in data management, QES can help health plans identify all the needed information more easily and efficiently. This not only saves time and resources but also ensures that members are receiving the most accurate information possible when choosing a healthcare provider.
Timing is Everything
So you have a robust provider directory–great, right? Not so fast, Charlie Brown. You’re only as good as your directory accuracy at the very moment your member is searching for care.
California regulations require information to be updated weekly in the event of a ‘triggering’ event, such as when they are:
- No longer accepting new patients.
- No longer under contract for the health plan.
- Their practice location or contact information has changed.
The most critical triggering event? When the health plan has received complaints about any of those scenarios. In an ideal world, each provider would inform you of changes. In the real world, sometimes members are the canary in the coal mine for data accuracy issues.
If a plan knows that a provider is retiring, no longer with the plan, or no longer with an associated provider group, they must delete the listing immediately. Health plans are expected to proactively reach out to provider groups at least once a year to confirm their data; twice-yearly check-ins are required for individuals. While the federal No Surprises Act (NSA) requires that health plans reach out every 90 days. Knowing your network isn’t half the battle; it IS the battle.
Accurate provider data is dependent on a proven approach.
ICYMI: You can easily detect any changes in your provider data by using Quest Enterprise Services. Plus, our provider outreach services can ease your workload with data attestation requests while improving data quality. We don’t wait for the football to be pulled–we double-check the placement before anyone kicks.
Lucy Learns Her Lesson
As a health plan, we know that you’re not planning on yanking the football away or providing knowingly inaccurate information. But the intent is not regulated–the reality is. While Charlie Brown might have a sore backside after a few failed attempts, the consequences for inaccurate provider directories are a bit more severe. In fact, since California’s SB 137 was implemented in 2016, six carriers have been hit with monetary fines for non-compliance.
A prime example of how even the smallest discrepancy can have major consequences is the Department of Managed Health Care’s (DMHC) ruling in 2021 that a health plan violated SB 137. It all started when a member of the plan was searching for an in-network psychiatrist in the online provider directory. After finding a psychiatrist, the member called the member service line to confirm the psychiatrist was in-network.
But when the member called the psychiatrist to make an appointment, they got a different story–the psychiatrist was no longer practicing at that location. This mistake ended up landing the health plan in hot water with monetary fines and a damaged reputation for not following state regulations.
But this scenario is not exclusive to this one health plan. It could happen to anyone who uses outdated or incomplete provider data.
That’s where Quest Enterprise Services (QES) comes in. With QES, you can ensure that your provider data is up-to-date and compliant with state regulations. By using QES to streamline your data management, you can focus your efforts on delivering high-quality, seamless, and efficient healthcare services to your members.
Ensuring Charlie's Goal
We all want Charlie to kick the football–and Quest Analytics is here to help. We are your go-to solution for maintaining compliance with CA SB 137-accuracy and ghost network regulations. By offering robust provider data management, we save you time and hassle. Avoid non-compliance consequences and embrace peace of mind today with QES. Let us help you support your plans and providers, so you can focus on delivering top-tier healthcare.
LEARN MORE ABOUT GHOST NETWORKS
Now that you know what we mean by ghost networks, explore the rest of our library!
- What Are Ghost Networks Read the Blog
- How Ghost Networks Impact Health Plans & Health Systems Read the Blog
- Four Steps to Increase the Value of Your Physician Network Download the Infographic
Proven Solutions for Your Provider Network Management
Looking to simplify your workload? Let Quest Analytics take on the heavy lifting! Our solutions and dedicated team specialize in provider data accuracy and provider network adequacy for various lines of businesses, including Medicare Advantage, Medicaid and Commercial. Schedule a strategy session today and see how we can help you every step of the way.