In its latest effort to increase transparency and improve patient access to information about their health care providers the U.S. Department Health and Human Services Centers for Medicare & Medicaid Services (CMS) published a Request for Information (RFI) on October 7, 2022, seeking input on creation of a national provider directory for use by patients, regulators, and insurers.
According to the announcement, the RFI was prompted by inefficiencies arising from “the fragmentation of current provider directories” maintained by providers, insurers and/or third-party sources that CMS believes could be remedied by a federal provider directory containing “digital contact information containing the most accurate, up-to-date, and validated . . . data in a publicly accessible index.”
The stated goal of the RFI is to examine the feasibility and requirements for a proposed National Directory of Healthcare Providers and Service (NDH). Responses to the RFI are due by December 6, 2022, and stakeholder comments already are being submitted.
Potential Impacts of the NDH
The RFI aims to gather information on the viability of a centralized, streamlined, and verified directory to address the challenges of availability and accuracy of data on health care providers. CMS appears likely to require all providers to participate in the directory, as the RFI does not discuss any opt-out of the initiative. According to CMS, the NDH will impact healthcare delivery in at least three ways: (1) potential reduction in administrative costs; (2) improvement of the accuracy and scope of provider directories; and (3) centralized support for patients choosing a provider.
- Economic Savings: The Council for Affordable Quality Healthcare (CAQH) estimated in 2019 that physician practices collectively spend $2.76 billion each year on directory maintenance, or roughly $998.84 per month per practice. As noted in the RFI, the CAQH estimated that moving directory data to single streamlined platform would save the average physician practice roughly $4,746 annually, or about $1.1 billion in collective nationwide savings.
- Consolidated Provider Directory Management and Use: Although CMS would lead the proposed directory, patients, providers, and payers will be able to utilize modern interoperable technology through use of an application programming interface (API). This technology would allow, for example, patients to locate providers through applications of their choosing, providers to submit prior authorization requests to payers, and payers to update their own directories from the NDH. For instance, if a provider relocates, it currently must update multiple systems and databases to account for their new office location, including both the National Plan and Provider Enumeration System (NPPES) and the Medicare Provider Enrollment, Chain, and Ownership System (PECOS), among other state-run or private systems. If implemented, the NDH will allow the provider to update their new location once through a single point of entry, mitigating the risk of inaccurate information across different systems.
- User Directory Access: Currently, patients choosing a provider must manually navigate a series of fragmented systems maintained by various entities to gather and compare provider information. By contrast, a national provider directory would provide a one-stop-shop for understanding the availability of healthcare providers—a process complicated by frequent inaccuracies in privately maintained provider directories. This may better-inform patients’ choice of insurance, choice of provider, and ability to make informed choices in general. Patients may also benefit from consumer health applications that combine NDH data with information on cost and outcomes, to provide patients a more complete understanding of their choice to enroll in a given plan, or to seek treatment by a given provider.
Interaction with Other CMS Interoperability Regulation
The RFI seeks to gather information consistent with efforts by CMS to facilitate interoperability and access to health information. Under the Consolidated Appropriations Act of 2021 those offering group or individual health insurance coverage must publish a provider directory of health care providers and their facilities. Group health plans and health insurance issuers also are required to routinely verify a provider’s address, name, specialty, and telephone numbers. The law further protects consumers from inaccurate identification of an in-network provider or facility in its directory by furnishing the items or services as if they were furnished by an in-network provider and by applying the deductible or out of pocket maximums in a similar manner. This RFI gathers information to support activities consistent with these statutory aims.
CMS conducts annual reviews to compare the accuracy of a covered plan’s machine-readable provider data files with the online provider directories and other data sources such as the NPPES. In its most recent review for plan years 2017-2021, CMS determined that only 28 percent of the provider information provided by plans matched the NPPES registry information for those providers. The RFI considers a method to improve accuracy of plan data—real-time access to the most up-to-date information in a central repository maintained by the federal government.
An NDH also would supplement federal efforts to establish “a universal floor for interoperability” through the Trusted Exchange Framework and Common Agreement (TEFCA). We previously covered the pending framework on this blog, including its potential to remove barriers to patients’ use of their own health care data. Both the NDH and TEFCA are likely to implement Fast Healthcare Interoperability Resources interfaces—a flexible technology for standardized exchange of health information. While both TEFCA and the NDH are still works in progress, these parallel efforts, using similar technology standards, reflect an increasingly consistent federal approach to ensuring patients can access and benefit from their health care data.
Keys to Effective Comments
CMS is requesting comments on three specific components of a potential provider directory:
- What technical or policy prerequisites would need to be met prior to developing an NDH?
- What specific risks or challenges should be anticipated throughout the system development life cycle of an NDH, and how can these risks and challenges be minimized?
- What are the most promising efforts that exist to date in resolving healthcare directory challenges, and how could CMS best incorporate these efforts into the requirements for an NDH? Which gaps remain that are not being addressed by existing efforts?
Reed Smith will continue to track developments related to this RFI and related federal efforts to improve health care interoperability. Please reach out to the health care attorneys at Reed Smith if you have any questions about how to offer effective comments on this initiative, or how other interoperability initiatives might affect your organization.