The REAL Health Providers Act

Last week, the Requiring Enhanced and Accurate Lists (REAL) of Health Providers Act was introduced by Senators Wyden D-Ore., Bennet D-Colo., and Tillis R-N.C. to strengthen accuracy and audit requirements for Medicare Advantage plan provider directories. The full text can be accessed here, and a summary of the bill can be accessed here. The full text is only 10 pages long, and it’s a surprisingly quick read.

A focus of the bill is to eliminate ‘ghost networks’, which is when providers who are listed in provider directories are not seeing new patients, are not participating in the listed plan, or are otherwise unavailable. Defacto reviewed the July 2023 Senate Finance Committee hearing on mental health ghost networks and highlighted testimony excerpts from the American Medical Association, Mental Health America, and American Psychiatric Association.

A significant portion of the REAL Health Providers Act reflects the No Surprises Act (which governs commercial health plans) and extends similar directory requirements to Medicare Advantage plans:
1) Directories need to be verified once every 90 days
2) If unable to verify, payers must indicate that information is not updated
3) Providers are to be removed within 5 days of non-participation
4) If a member sees an out-of-network provider who was listed on the provider directory, the member is only responsible for the cost sharing amount as if the provider were in-network

There are new directory requirements, around accuracy analysis of directories, that are beyond the No Surprises Act and previous Medicare Advantage requirements:
1) Payers must conduct annual analysis of the accuracy of plan directories
2) Payers must submit a report to the government on the analysis
3) CMS will post accuracy scores of payers’ directories in a machine-readable file

If the bill passes, the effective date will be 2026, and payers will have a few years to comply. Since CMS began auditing Medicare Advantage plans starting in 2016, many payers also began auditing their directories and have a process in place. CMS will need to decide whether to establish a standardized audit methodology for MAOs to follow, or formalize and publish the audit approach they have been using to date. Payers, accordingly, need to adapt their current audit approaches, or spin up parallel audit efforts that align with the prescribed assessment model if it is divergent from how they are currently auditing their directories.

The bill also guides CMS to assess and communicate best practices for directory maintenance to Medicare Advantage plans, specifically providing guidance on data sets (including public data sets) that could be useful to improve directory accuracy. The industry has matured since the first round of directory rules were established, and it will be important to assess how some payers have out-performed others in terms of data accuracy, timeliness, and completeness. If we can understand the interventions employed by these ‘positive outliers’, then it will be possible to replicate and scale the performant interventions across all payers. Additionally, public data sets like directory data sourced from hundreds of payers’ Provider Directory APIs could be used as data cleansing signal.

We will see if the REAL Health Providers Act passes, how CMS chooses to implement it, and how quickly payers are able to adapt to assessing their own accuracy ‘out in the open’. With increased availability of data as a result of CMS transparency and interoperability rules, the federal government will have more efficient tools to monitor and enforce directory accuracy. Non-compliance to existing interoperability rules (that have been in place since 2021) around Provider Directory APIs, however, should not be considered a strategy to obfuscate data from the federal government. Those who have yet to provide functional Provider Directory APIs, and those who are switching vendors, should see the pending REAL legislation as motivation to quickly comply. Finally, there is an opportunity for payers to collaborate with those ‘app developers’ that are already integrated with their Provider Directory APIs, and get ahead of the upcoming scrutiny that will come with new legislation and subsequent rule making. Industry feedback on directory data accuracy, completeness, and availability can catalyze a virtuous cycle of provider directory improvement that will make them more usable for members and prospective members.