Interoperability: Provider network directories

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Summary

CMS is requiring qualified health plans (QHPs) to ensure that their provider network directories are accurate, up-to-date, machine-readable and publicly available. This has not been done before and faces a number of logistical and technical challenges. Our goal is to help facilitate adoption of standards and formulate an implementation plan that's acceptable to plans, providers and other industry participants.

Go to Technology Standards page

Background information


Section 3. Network Adequacy
i. Network Adequacy Standard
ii. Provider Directory Links

ii. Provider Directory Links

Pursuant to the 45 C.F.R. 156.230(b), CMS, as administrator of the FFMs, will require QHPs to make their provider directories available to the FFMs for publication online by providing the URL link to their network directory. As stated in the 2016 Payment Notice Final Rule, CMS is strengthening the provider directory requirement. Specifically, a QHP issuer must publish an upto-date, accurate, and complete provider directory, including information on which providers are accepting new patients, the provider’s location, contact information, specialty, medical group, and any institutional affiliations, in a manner that is easily accessible to plan enrollees, prospective enrollees, the State, the FFM, HHS, and OPM. A provider directory will be considered up-to-date if it is updated at least monthly and easily accessible when the general public is able to view all of the current providers for a plan in the provider directory on the issuer’s public website through a clearly identifiable link or tab without having to create or access an account or enter a policy number. The general public should be able to easily discern which providers participate in which plan(s) and provider network(s). Further, if the health plan issuer maintains multiple provider networks, the plan(s) and provider network(s) associated with each provider, including the tier in which the provider is included, should be clearly identified on the website and in the provider directory.

CMS is also requiring issuers to make this information publicly available on their websites in a machine-readable file and format specified by HHS, to allow the creation of user-friendly aggregated information sources. The purpose of establishing machine-readable files with this data is to provide the opportunity for third parties to create resources that aggregate information on different plans. We believe this will increase transparency by allowing software developers to access this information and create innovative and informative tools to help enrollees better understand the availability of providers in a specific plan. CMS established these provider directory requirements to enhance the transparency of QHP provider directories and to help consumers make more informed decisions about their health care coverage. The content of this section applies to all QHP issuers in the FFMs, including in States performing plan management functions in the FFM.

Comments and responses are available for review

To facilitate this change, we proposed adding § 156.230(c) to require QHP issuers to make available and submit to HHS information about providers in its provider networks.

We specifically solicited comments on this requirement and other options, including the technical requirements for developing a machine-readable file and format for a provider directory, as well as other technical considerations, such as processes and considerations that should be taken into account. We have established these requirements to enhance transparency of QHP provider directories and to help consumers make more informed decisions about their health care coverage. We solicited comments on these proposed requirements, including how frequently provider data should be updated, and whether additional types of information should be required to be included in the provider directory. We understand the complexity of this undertaking, and recognize that this will require issuer resources. Therefore, HHS intends to provide additional details about the data submission requirements.

Implementation challenges


  1. The regulations are asking insurance plans to update the provider directories at least monthly, which might include provider locations, specialties, and whether they're accepting new patients. But the providers are the ultimate stewards of such information and the plans aren't always notified of changes.

  2. Since the penalties are imposed on insurance plans, the economic incentives for providers to update the plans with any changes need to be determined. One option might be for plans to establish "carrots and sticks" for providers, based on number errors that get reported by patients throughout the year. Another option might be NCQA-like accreditation, where providers are independently evaluated on accuracy of information they provide to plans.

  3. Some of the fields identified in the proposed standard originates with providers, while other can be best updated by issuers. If providers would ultimately be held responsible for a portion of the data, we would want to split the schema based on who is submitting the data. Otherwise, neither party would be able to submit complete files.

  4. The "Accepting Patients" field could be misleading to consumers if it's only yes/no. A doctor who is labeled as not accepting patients could choose to see new patients under a wide range of circumstances and vice versa. For example, such changes occur when current patients leave, based on time of day for open access scheduling, for relatives, when the backlog decreases, etc.

  5. Historically, some health insurers have been protective about the ability for the public to download their provider network directories. To what degree can this information be considered confidential and proprietary, given the current regulations.

  6. Having a standard for the required "machine-readable format" would make it possible to build services useful for consumers, plans and providers. But there was no specific standard indicated in the CMS rule. The options are discussed in the Technology Standards section below and on page Implementation: Provider network directories/Standards.

  7. Implementation would be easier if there was a precedent of provider directories being implemented with Medicare Advantage programs. But at the moment, the FFMs are ahead of Medicare in this regard. Medicare would need to first establish similar rules to obtain the needed regulatory authority. In the mean time, perhaps there's an opportunity for voluntary participation. Current MA regulations around provider directory requirements are in Section 100 of Medicare Marketing Guidelines.
    • According to Medicare Advantage 2016 Final Call Letter
      • "Guidance to Verify that Networks are Adequate and Provider Directories are Current: 42 CFR § 422.111 requires MAOs to disclose the provider directory; § 422.112 requires MAOs maintain and monitor the network of providers and to provide adequate access to covered services." MAOs are also asked to "Develop and implement a protocol to effectively address inquiries/complaints related to enrollees being denied access to a contracted provider with follow through to make corrections to the online directory."
      • Details a "...three-pronged approach to monitor compliance with the regulations": 1. Direct monitoring; 2. Use of audit protocol; 3. Compliance / enforcement actions. (Separately, Medicare is planning to take a sampling of plans and providers to gauge the realistically expected accuracy of the network directories for the purposes of formulating recommendations.)
      • In relation to QHP guidelines: "A few commenters suggested that requirements for online directory updates should conform to those established for the Qualified Health Plans (QHPs) in the Marketplace." Also, "Overall, most commenters supported CMS’s three-pronged approach to monitor compliance, and intent to consider instituting a requirement for MAOs to submit, and regularly update, network information to CMS in a standardized, electronic format for eventual inclusion in a nationwide provider database."
      • Planned for 2017
        In addition, CMS is considering, beginning on or after CY 2017, instituting a new regulatory requirement for MAOs to provide, and regularly update, network information in a standardized, electronic format for eventual inclusion in a nationwide provider database. This approach would build upon other Departmental efforts, including pursuit of similar requirements for QHPs in the Health Insurance Marketplace. CMS’s goal in this effort would be to make provider network data readily available to beneficiaries, stakeholders, and the public in a uniform format, based on the best available consensus-based standards that would be required by CMS. CMS anticipates that a common format and standard would enable greater interoperability across provider directories and more up-to-date information in provider directories maintained by health plans, at a state level, and in national databases such as the National Plan and Provider Enumeration System. Standardized provider directories would serve as a useful tool to search for individual providers and determine, on a readily-accessible, provider-specific basis, every MA plan for which a specific provider is currently contracted. We believe this approach could also be leveraged by application developers to create user-friendly search applications that will be more accessible, up-to-date, and useful for consumers than the current, non-standardized websites or printed provider directories. This approach would enhance the transparency of provider networks, and enable beneficiaries to make informed decisions about their health care coverage.


  8. Typically, provider directory information, such as NPPES and PECOS, is maintained and published by CMS's CPI group. But this rule is managed by CMS's CCIIO group. Additionally, there might be confusion among insurers who are both on FFM exchanges and offer Medicare Advantage plans, since the requirements for provider directories are guided by two different sets of regulations.


Technology Standards

Alternatives

There's no mandated standard for network provider directories. Potential candidates are discussed below and in detail on Implementation: Provider network directories/Standards page


  1. QHP Provider Formulary APIs https://github.com/CMSgov/QHP-provider-formulary-APIs.
  2. schema.org-type standard proposed by Aneesh Chopra for this purpose is File:Schema.org US Health Insurance Networks.pdf

  3. Model for provider directory document as requested for Medicare Advantage plans: media:Medicare Advantage - 2016 Model Provider Directory 05052015 FINAL.pdf

  4. IHE's HPD+ (http://ihe.net/uploadedFiles/Documents/ITI/IHE_ITI_Suppl_HPD.pdf) proposed for use with ONC's EHR certification for the HPD (Healthcare Provider Directory) capability. It makes significant distinction in the fields used for Individual Providers vs Organizational Providers.

Data Model

The schema proposed for use by QHP (Qualified Health Plans) on health insurance marketplaces can be found on GitHub: https://github.com/CMSgov/QHP-provider-formulary-APIs. Designing an improved model for the provider directory and plan coverage standards required analysis of:

  1. CMS's [templates for gathering QHP data](https://www.cms.gov/CCIIO/Programs-and-Initiatives/Health-Insurance-Marketplaces/qhp.html) on: Network Adequacy and Plans and Benefits
  2. CMS's [public use files of historical data](http://www.cms.gov/CCIIO/Resources/Data-Resources/marketplace-puf.html) on: Networks, Plan Attributes, Benefits and Cost Sharing
  3. Collected input from the industry workgroup, consisting of payers, payer-provider intermediaries, providers and consumer applications

The data model now looks like this:

Data model for provider network directories


Data for Download

As of November 2015, CSV-format files containing links to provider network directory data are available for download as "Machine-readable URL PUF" (aka, MR-PUF). These links are contributed by QHP issuers via CMS's HIOS system and intended for open enrollment for the 2016 plan year.

The downloads are located at https://www.cms.gov/CCIIO/Resources/Data-Resources/marketplace-puf.html and include issuer-level URL locations.



  • MR-PUF file download direct link: http://download.cms.gov/marketplace-puf/2016/machine-readable-url-puf.zip
    • Note that Open Enrollment 2016 is the first time this file is available
    • URLs provided in the PUF are typically index JSON pages that point to the URLs for the required schemas:
      1. plans.json: Contains a list of health plans and their corresponding network of providers and formularies. Subtypes: Network, Formulary, Cost Sharing, Benefits
      2. providers.json: Contains a list of providers, both individual and facilities, and the plans that cover their services. Subtypes: Plans
      3. drugs.json: Contains a list of drugs and the plans that cover them. Subtypes: Plans
    • Some plans have missing data in the URL field, indicated by "NOT SUBMITTED"
    • Disclaimer for MR-PUF: https://www.cms.gov/CCIIO/Resources/Data-Resources/Downloads/Disclaimer_for_Machine_Readable.pdf



  • Limitations
    • Accuracy & completeness: The data contained throughout these files is self-reported by the issuers. Therefore, quality and completeness cannot be assured. Since 2016 is the first year this is implemented, some issuers have had difficulty delivering the requested data.
    • Inadequate schema: Some issuers and industry experts have stated that the level of detail possible with the specified schema is not sufficient to accurately represent the complexity with which networks are currently designed. As a result, the data may not adequately and reliably help consumers pick plans based on providers available.
    • Not for consumers: A consumer facing look up tool has not yet been provided by CMS, as of the start of Open Enrollment 2016. For consumers, the JSON files are difficult to read and the fragmented storage of the data makes comparisons between issuers difficult. It is expected that third parties will load this data and provide consumer with helpful applications. It's possible that in the future CMS would provide their own lookup tool as well.


FHIR

CMS/CCIIO did not specify the transport mechanism for the QHP schema. The only requirement is to register the URL with HIOS (Health Insurance Oversight System). The URLs could be to a static page or to a dynamic RESTful query. CMS or third party services could provide significant value to both consumer applications and transaction oriented systems by adding a RESTful FHIR layer. Ideally, this would be done in front of globally aggregated datasets that have been registered in HIOS.

Much of the usefulness for machine readable provider networks is around enabling consumers to ask certain common questions when they need to select an insurance plan. (For example: Which insurance plans is my doctor in? Is she taking new patients at a desired facility under a particular plan? What plans have the specialists I need in a specific geographic region?) These questions could easily translate to FHIR queries, since search on any portion of the provider network schema could be exposed. Additionally, by adding search capability, response record count limits, and pagination, load from traffic on aggregated data servers could be much more efficient.

Example of FHIR implemented for provider directories, although limited to NPPES data model. Here's the codebase (https://github.com/DavidXPortnoy/nppes_fhir_demo), created by Dave McCallie. There's a live non-production sandbox version here: http://fhir-dev.ddod.us:8080/nppes_fhir. Sample queries:

This server could easily be expanded to accommodate the full provider network directory schema, including components of provider demographics, facilities, organizations, credentialing, insurance plans, plan coverage, and formularies.



Planning

Deployment strategy

  • Once the QHP schema is finalized by CMS/CCIIO, the PDWG (provider directory industry workgroup) can use this as a basis for an interoperable standard that issuers, providers and intermediaries can leverage to:
    • Minimize the total burden to issuers and providers of keeping provider network directories up to date
    • Provide more accurate, useful and timely information to consumers
  • CMS's proposed schema would be a subset of the ultimate standard, which could be used more broadly than for QHPs on FFMs.
  • PDWG plans to team up with Google to submit this standard to Schema.org.


Measuring Progress

The original driver for creating a machine readable provider network directory standard is to address the overall perception of high consumer complaints. The main complains were around not having correct information when purchasing coverage. That's because they would find out after its too late that their desired doctors are not taking their plan or not accepting patients under their plan.

In order to have a sense for how well the implementation of the new standard is meeting this driver, we need to establish quantitative metrics that could be consistently obtained for both before and after the rule has been implemented. Some options are:

  1. It would be good if CMS/CCIIO would establish a survey of exchange shoppers that are focused on the metrics needed
    • But since such a survey wasn't around prior to the rule, it's not a good benchmark for comparison

  2. Medicare gathers consumer complaint data
    • But the Medicare customers don't intersect with those buying on exchanges

  3. Issuers' own records on consumer complaints
    • But individual issuer are reluctant to publish data that has negative connotations, especially if their competitors don't have to

  4. Get these statistics from privately run marketplaces outside of HealthCare.gov, such as eHealth Insurance, GetInsured and GoHealth.
    • These companies may not have the same reluctance as issuers to publish negative consumer data.
    • They could actually benefit from doing so. It could be leveraged as a differentiator, plan selection tool for consumers, and competitive insight tool for issuers.

  5. Once FFS Medicare (Parts A and B) and Medicare Advantage (Parts C and D) adopt a similar machine-readable standards, their existing tools can be used for metrics:
    Consumer complaints to Medicare.png
    • FFS Medicare:
      1. MAISTRO (Medicare Administrative Issue Tracker and Reporting of Operations System): is used to collect and report complaints and inquiries related to fee-for-service Medicare (that is, Medicare Parts A and B) that come directly to and are managed by CMS staff.
        • Potential applicable categories: Enrollment/entitlement/eligibility and Provider enrollment/participation requirements.
      2. Fee-for-Service (FFS) CAHPS: Collects information from Medicare beneficiaries enrolled in the FFS program. The survey targets a sample of approximately 275,000 beneficiaries. The questions on the survey relate to the enrollee’s experience of care with Medicare and their FFS provider.
    • Medicare Advantage:
      1. CTM (Complaint Tracking Module): registers and categorizes the complaints related to Medicare Parts C and D that are logged by 1-800-MEDICARE and CMS staff.
        • Potential applicable categories (listed in order of highest volume): Enrollment / Disenrollment, Pricing/premium/co-insurance, Benefits/access, Marketing, Plan administration.
      2. Medicare Advantage and Prescription Drug Plan CAHPS: Collects beneficiaries’ experiences with, and ratings of, Medicare Advantage (MA-only) plans, Medicare Advantage Prescription Drug (MA-PD) plans, and stand-alone Medicare Prescription Drug Plans (PDP). The health plan survey has been conducted annually since 1998, while the drug plan surveys were since 2007.
      3. Medicare Advantage and Prescription Drug Plan Disenrollment Reasons Survey: captures why beneficiaries choose to voluntarily disenroll from PDP or MA contracts.
    • Medicaid:
      1. Nationwide Adult Medicaid CAHPS: Survey beneficiaries to attain national and state-by-state estimates of their access, experience and satisfaction with care across financing and delivery models (e.g., managed care and fee-for-service) and population groups (e.g., disabled individuals or dually eligible individuals).





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