Every practice manager knows the importance of creating policies and processes to follow when a new provider joins — but it’s important to remember that you must also create know what to do when a provider leaves your practice. And even if you have a list you’ve been using for years, there’s one item that’s required now that wasn’t in the past — updates to your provider directory.
Here’s what it is: The No Surprises Act, which went into effect January 1, is well known for its requirement to give patients estimates of what they’ll owe you. But one slightly less-publicized part of the rule involves creating a provider directory and validating it with every payer. And if you don’t update your directory when providers leave, your payer contracts could be terminated, you could face fines, and patients can ask for reimbursement back if they relied on incorrect information and paid too much for services.
Pinpoint the Consequences
The provider directory is more than a guidebook for patients. It’s a contractually required document that you must maintain under federal rules that tells patients which providers are in-network as part of their insurance plan and which aren’t. Under the No Surprises Act, patients are entitled to access this information so they can make good faith decisions about whether to seek in-network or out-of-network care.
Check out a few key facts that you must know if you want to stay on the right side of the provider directory rules when providers leave your practice.
You’re Required to Submit Quarterly Updates — But Don’t Wait for Those
Your insurer will send you a validation request every 90 days, asking you to review your provider directory information and submit any changes. However, if a provider leaves your practice during the quarter, you should not wait for their validation request to update your provider directory. Instead, submit your information as soon as you know the provider is departing.
The process will differ depending on your insurer’s requirements, but in most cases, your payer’s website will have a page where you can submit your directory update. In other cases, the insurer may require that you fill out a directory maintenance form that you email to your payer contact. But it’s up to you to ensure that you submit the updated information quickly rather than waiting for the quarterly validation period.
Don’t Count on Others to Let Your Payers Know
When a provider leaves your practice, you must adjust your files in the PECOS and CAQH databases. However, you cannot rely on outside entities like your CAQH system to automatically delete your information from payers’ provider directories. It’s your responsibility to update your provider directory information as soon as you know that a provider will be departing your practice.
If you don’t keep your provider directory up to date, it can clearly create a ripple effect that can have lasting implications and high costs. That’s why it’s imperative for your practice to add this step to your provider exit checklist.
To learn more about what to do when physicians join or leave your practice, check out the online training session, Speed up Credentialing & Reimbursement for New Providers, presented by David J. Zetter, PHR, SHRM-CP, CHC, CPCO, CPC, COC, PCS, FCS, CHBC, CMUP, PESC, CMAP, CMAPA, CMMP, CMHP. During the 60-minute training, you’ll find out how to adjust your provider directory when providers leave your practice so you won’t face fines and stalled reimbursement.
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