The Requiring Enhanced and Accurate Lists (REAL) of Health Providers Act, also known as the REAL Health Providers Act, was introduced by U.S. Senators Ron Wyden (R-OR), Michael Bennet (D-CO), and Thom Tillis (R-NC) and has bipartisan support. This legislation aims to ensure that Medicare Advantage plans protect seniors from unexpected healthcare costs and maintain accurate provider directories. This legislation mandates specific requirements for maintaining and verifying provider information. Orderly is committed to our customers’ success in this evolving regulatory landscape, ensuring seamless compliance and efficient provider data management.
Understanding the REAL Health Providers Act (S. 3059):
The Act, once passed, will amend title XVIII of the Social Security Act, setting forth requirements for Medicare Advantage plans to maintain accurate and up-to-date provider directories. It was reviewed by the Senate Finance Committee in October 2023 and has bipartisan support. We believe understanding the critical elements and their implications is vital for informed decision-making in healthcare.
Key provisions include:
- Maintaining an Accurate Provider Directory:
- Directories must include essential details like provider names, specialties, contact information, and telehealth capabilities.
- Regular Verification:
- Directories must be verified every 90 days, and if verification fails, an indication must be provided.
- Prompt Removal of Non-participating Providers:
- Providers must be removed from the directory within five business days of non-participation.
- Cost Sharing Protections:
- If a member relies on incorrect provider network information, they should only be responsible for in-network cost sharing.
- Annual Accuracy Analysis:
- Beyond the No Surprises Act and previous Medicare Advantage requirements, the REAL Health Providers Act mandates payers to conduct an annual analysis of the accuracy of plan directories and submit a report to the government. CMS will then post the accuracy scores of payers’ directories.
How Orderly Health Ensures Compliance:
- Automated and Accurate Directory Management:
- Orderly aligns with the Act’s requirements for regular verification and swift provider information updates through its AI-driven solutions that automate the process of maintaining accurate provider directories and verifying essential fields. This process is critical for preventing "ghost networks."
- Enhanced Provider Data Verification:
- Orderly Health ensures that managed care organizations can confidently meet the CMS 90-day verification mandate by continuously updating and verifying provider data and pairing this with a streamlined and budget-optimized process. This can reduce the risk of patients inappropriately seeking out-of-network care due to stale and incorrect directory data.
- Streamlined Provider Removal Process:
- The platform’s efficient data management tools enable quick removal of non-participating providers, ensuring directories are always current and compliant.
- Annual Accuracy Reports:
- Orderly’s Data Health Assessments are scheduled as part of a subscription to our Data Updates service. These assessments report robust and multi-dimensional measures of accuracy against benchmarks and highlights areas of strength and opportunity. The Data Health Assessments may be submitted to government agencies in order to comply with the proposed requirements in the REAL Health Providers Act.
- Comprehensive Data Insights and Reporting:
- A standard feature of the Orderly platform is a recurring Data Health Assessment, which can be used to adhere to new reporting requirements and maintain transparency both internally and with regulators.
The REAL Health Providers Act presents a new set of challenges and responsibilities for healthcare organizations. With its cutting-edge technology and deep expertise in healthcare data management, Orderly is perfectly positioned to help organizations navigate this new regulatory landscape. By partnering with Orderly, healthcare providers can ensure compliance with the Act, enhance operational efficiency, and ultimately deliver better patient care.
Prepare for the future of healthcare compliance with Orderly.
Explore OrderlyHealth.com to learn more about how we can help you align with the REAL Health Providers Act and enhance your provider data management.