In the complex world of healthcare, health plans are constantly striving to provide excellent care while adhering to a web of regulations. Effective Provider Data Management (PDM) is crucial in this landscape. Several key pieces of legislation, including the Affordable Care Act (ACA), the No Surprises Act (NSA), and the Consolidated Appropriations Act (CAA), have significantly elevated the importance of PDM in recent years. Furthermore, respected accrediting bodies such as the National Committee for Quality Assurance (NCQA) and URAC play a vital role in establishing guidelines for this essential function. This article will explore how Network by HealthStream® empowers health plans to meet these legal and industry standards, fostering a more dependable and transparent healthcare ecosystem.
Legislation and Provider Data Management
Government legislation plays a foundational role in shaping how health plans operate, particularly concerning provider data. Accurate and accessible provider information is not just about administrative efficiency; it’s mandated by law to protect patients and ensure the smooth functioning of the healthcare system.
1. The Affordable Care Act (ACA) and Network Adequacy
The Affordable Care Act (ACA), enacted in 2010, brought about sweeping changes to the healthcare system, including provisions directly impacting PDM. A core tenet of the ACA is ensuring network adequacy, meaning health plans must offer networks of providers that are sufficient to meet the needs of their members.
Network by HealthStream Impact:
- Ensuring Network Adequacy: The ACA mandates that health plans maintain provider networks that are adequate for the demographics of the geographic areas they serve. HealthStream’s Network Adequacy tool provides a simple yet powerful way to assess your network strength. It allows for quick comparisons between the number of primary and specialist providers you have versus the number needed to meet member demand. This ensures that health plans can proactively identify and address any gaps in their network, fulfilling ACA requirements.
- Supporting Quality Reporting: For health plans participating in Medicare Advantage (Part C) or Medicaid Managed Care, the Centers for Medicare & Medicaid Services (CMS) requires assurance of care quality within their networks. This often involves rigorous evaluations like site surveys and audits to verify adherence to CMS quality standards. Network by HealthStream’s checklist feature provides a robust solution for documenting and tracking these essential site surveys, simplifying the process of demonstrating ongoing compliance.
2. The No Surprises Act (NSA) and Provider Directory Accuracy
The No Surprises Act (NSA), effective January 1, 2022, is landmark legislation designed to shield patients from unexpected medical bills, particularly those arising from out-of-network care. Surprise billing can occur even when patients utilize in-network facilities but unknowingly receive care from out-of-network providers within those facilities.
Network by HealthStream Impact:
- Enhancing Provider Data Accuracy: The NSA directly addresses the issue of surprise bills by aiming to prevent patients from unknowingly receiving out-of-network care. Network by HealthStream plays a crucial role in supporting these protections by ensuring provider network status is meticulously maintained and that provider enrollment in specific plan products is accurately aligned. This meticulous data management significantly decreases the chance of patients inadvertently receiving out-of-network care, directly mitigating the core problem the NSA seeks to solve.
- Streamlining Provider Directories: Accurate and up-to-date public provider directories are a cornerstone of NSA compliance. Network by HealthStream acts as the downstream system of record, empowering health plans to maintain these directories with precision. Through the Connect API, Network by HealthStream facilitates the seamless flow of current demographic, education/training, location, and plan participation information, ensuring public directories are reliable and compliant with NSA mandates for transparency.
3. The False Claims Act (FCA) and Fraud Prevention in Healthcare Programs
The False Claims Act (FCA), initially enacted during the Civil War and significantly amended in 1986, stands as a primary legal tool in combating fraud and abuse within federal healthcare programs. While not explicitly focused on PDM, the FCA’s broad reach necessitates accurate and truthful data in all aspects of healthcare administration, including provider data. Inaccurate or intentionally misleading provider data could potentially lead to false claims and subsequent FCA violations.
Network by HealthStream Impact:
- Promoting Data Integrity: By providing a centralized, auditable, and accurate system for managing provider data, Network by HealthStream indirectly supports FCA compliance. The system’s robust data management capabilities help minimize errors and discrepancies that could inadvertently contribute to false claims. Maintaining a clear and verifiable record of provider information is essential for demonstrating due diligence and preventing fraudulent activities.
4. Consolidated Appropriations Act (CAA) and Transparency Mandates
The Consolidated Appropriations Act (CAA) of 2021 is a comprehensive legislative package addressing various aspects of healthcare, including surprise billing, increased transparency, and insurance market reforms. Building upon the NSA, the CAA further emphasizes the need for readily accessible and accurate provider information for patients.
Network by HealthStream Impact:
- Enhancing Transparency: The CAA’s focus on transparency aligns perfectly with Network by HealthStream’s capabilities. The platform’s ability to maintain accurate and up-to-date provider directories directly supports the CAA’s transparency goals. By making it easier for health plans to provide clear and reliable information to their members, Network by HealthStream helps facilitate compliance with the CAA’s broader objectives of empowering healthcare consumers.
Accrediting Bodies and Provider Data Standards
Beyond legislation, accrediting bodies play a crucial role in shaping best practices and setting standards for healthcare quality, including PDM. Organizations like NCQA and URAC provide frameworks that health plans voluntarily adopt to demonstrate their commitment to quality and patient safety.
National Committee for Quality Assurance (NCQA) and Credentialing Standards
Established in 1990, NCQA has been a leading force in healthcare quality standards for decades. Driven by the growth of managed care and the increasing diversity of provider types, NCQA emerged to standardize quality measures across the healthcare spectrum. Today, NCQA’s quality benchmarks, such as the Healthcare Effectiveness Data and Information Set (HEDIS) and the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS), are widely recognized indicators of healthcare quality.
NCQA places significant emphasis on the verification and validation of provider data as a cornerstone of patient safety. As a result, NCQA has become the foremost accrediting body for healthcare organizations (both providers and payors) concerning credentialing practices. NCQA accreditation rigorously examines various aspects of credentialing, including provider rights, committee review processes, cycle lengths, delegation agreements, audit procedures, and data governance and backup protocols.
URAC and Operational Flexibility in Accreditation
Also founded in 1990, URAC is another independent non-profit organization dedicated to promoting healthcare quality through accreditation, certification, and measurement programs. URAC initially focused on improving utilization review processes but has expanded to encompass a broad range of healthcare operations.
While NCQA is more frequently utilized for health plan credentialing accreditation, URAC remains a significant and respected accrediting body. URAC accreditation is often favored in situations where health plans prioritize operational flexibility and specialized services. URAC’s standards can be particularly appealing for plans that focus on or offer niche services, such as telehealth, digital health services, or pharmacy benefit management.
Network by HealthStream: Supporting NCQA and URAC Accreditation
Whether pursuing NCQA or URAC accreditation, Network by HealthStream provides the healthcare industry’s only dedicated network relationship management (NRM) system. Network by HealthStream streamlines the entire PDM process, from initial provider data onboarding from national sources to ongoing data updates across your entire organization. Leveraging industry-leading Primary Source Verification (PSV) tools, Network by HealthStream ensures data accuracy and integrity, simplifying the path to compliance and accreditation. By continuously streaming updated provider data across all relevant systems, Network by HealthStream ensures that health plans operate with the most current and reliable information, regardless of their chosen accreditation path.
