Among the lesser known provisions of the No Surprises Act are those that seek to improve the accuracy of in-network provider directories maintained by insurance plans. Since the goal of the No Surprises Act is to ensure patients do not receive unexpected out-of-network bills, keeping accurate in-network provider directories serves as a first line remedy.
While more complete rulemaking to address provider directories is expected later in 2022, the Consolidated Appropriations Act, 2021 (No Surprises Act, Sec. 116) laid out the general groundwork for both payers and providers to tackle the problem of out-of-date and inaccurate directories. The law also includes some protection for patients who rely on bad information in a directory and end up with a surprise out-of-network bill.
Payer Requirements
Payers are required to verify and update provider directories at least every 90 days, develop a procedure for removing providers that cannot be verified, and update the directory within two business days when updates are received. As well, payers must respond to patient requests regarding the network status of a provider within one business day and retain that communication for two years.
The directories themselves must be available on the payer’s website, and include the following details about all contracted providers:
- name,
- address,
- specialty,
- telephone number, and
- digital contact information.
As well, all printed directories must include the date the directory was printed, along with a note indicating that the information contained in the printed directory was accurate as of the date of publication and the most current provider directory information is available on their website.
Provider Requirements
At a minimum, all providers and healthcare facilities are required to submit provider directory information to an in-network plan or issuer:
- when they begin a network agreement;
- when they terminate a network agreement;
- when there are material changes to their directory information;
- at any other time determined appropriate by the payer, provider, facility, or Secretary of Health and Human Services (HHS).
The following information must be submitted for the provider directory:
- Names, addresses, specialty, telephone numbers, and digital contact information of individual health care providers; and
- Names, addresses, telephone numbers, and digital contact information of each medical group, clinic, or health care facility.
The law also allows providers to require, as part of the terms of their contract, that the payer must remove the provider from the directory upon termination of the contract and bear any financial responsibility for providing inaccurate network status information to an enrollee.
Despite the delay in rulemaking around these provisions, providers and healthcare facilities were required to have business processes in place no later than January 1, 2022, to ensure timely provision of provider directory information to payers.
Patient Protections
If a patient relies on incorrect provider directory information to receive items or services from an out-of-network provider or facility, both payers and providers are responsible to bear the financial responsibility of the error.
The payer must limit cost-sharing and apply the deductible or out-of-pocket maximums as if the items or services had been furnished by an in-network provider or facility, and the provider or facility must limit their billing to in-network cost-sharing.
If the patient relied on incorrect provider directory information, received a bill for more than the in-network cost-sharing amount, and paid the bill, then the provider is required to reimburse the patient for the full amount paid in excess of the in-network cost-sharing amount, plus interest.
These patient protections apply to items or services furnished based on incorrect provider directory information in plan years beginning on or after January 1, 2022.
Learn More
For more information about provider directory provisions of the No Surprises Act, check out the following resources:
- The Consolidated Appropriations Act, 2021 (No Surprises Act, Sec. 116, page 1699)
- High-Level Summary of the No Surprises Act from the American Medical Association
- FAQs for Providers about the No Surprises Rules from the Center for Medicare and Medicaid Services
- The No Surprises Act’s Continuity of Care, Provider Directory, and Public Disclosure Requirements from the Center for Consumer Information & Insurance Oversight (CCIIO)
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