Since you asked: What is the employer’s role in maintaining accurate provider directories?

Question

Recent articles have stated that provider directories used by group health plans are often not accurate, despite the new requirements in the No Surprises Act. Does an employer have any responsibility to take action as the sponsor of a group health plan?

Answer

Yes, plan sponsors should be reviewing their group health plan provider directories with their third-party administrators (TPAs) and carriers to make sure these directories are up to date and accurate.

No Surprises Act requirements

For plan years beginning in 2022, the No Surprises Act (NSA) requires group health plans to establish provider directory databases on their public websites that list required information for each in-network healthcare provider and facility. “Required information” includes the provider’s name, address, specialty, telephone number and digital contact information.

Note: If the group health plan maintains a print provider directory in addition to the digital database, the print directory must include a notification that the printed information was accurate as of the date of publication and that enrollees should consult the plan’s public website database or contact the plan for the most current provider directory information.

The NSA further requires each group health plan to establish a process to verify and update, at least once every 90 days, the information included in the provider directory database. The process must include a procedure for removing a provider or facility from the database if the plan has been unable to verify the directory information during a period specified by the plan and must also provide for updating the database within two business days after the plan receives new provider or facility information.

Plans must also establish a protocol that meets specified requirements for responding to plan participant requests about whether a provider or facility is in-network.

Consequences of inaccurate provider directory information

If an out-of-network provider is inaccurately identified as being in-network in a provider directory, and an individual obtains items or services from that provider, the NSA requires a plan to do both of the following:

1. Limit cost-sharing for those items and services to an amount that is the same or less than the cost sharing that would apply for an in-network provider.
2. Apply the deductible or any out-of-pocket maximum as if the items or services were furnished by an in-network provider.

These NSA provisions apply to plan years beginning on or after January 1, 2022. Affordable Care Act FAQs Part 49 direct group health plans to implement these provisions using a good faith, reasonable interpretation of the statute until further rulemaking is issued.

Takeaways

• TPA/administrative services only (ASO) agreements may need to be revised as legal requirements change. For example, the NSA (and the other provisions of the Consolidated Appropriations Act, 2021) imposed many additional obligations on group health plans, including requirements to make available a price comparison tool, maintain a website database with provider directory information, furnish “advanced explanations of benefits” in certain situations and provide disclosures regarding protections against surprise medical billing. Plan sponsors will want to review their TPA/ASO agreements with legal counsel to determine whether the agreements address the accuracy of provider directories.
• Plan sponsors should continue to ensure that their TPAs have a process in place to monitor and update information in provider directory databases on a regular basis.