California Doctors Now Required to Provide Timely Practice Updates

 

On July 1, a new law went too effect that requires health plans to comply with uniform standards and provide timely updates (practice address, license number, etc.) to their provider directories. The intent of the new law, SB 137, is to provide patients with more accurate and complete information as to which providers are participating in the plan's provider network.

Doctors are are required to respond to a plan's request for verification of directory information within 30 days. Failure to respond within the required time frames will result in payment delays or reductions. The law requires that insurers must offer an online provider directory to the public, without any restrictions or limitations, that is searchable by provider name, practice address, city, ZIP code, license number, NPI, type of practitioner, provider license number, practice group or clinic name, and provider language. The plan directories will also note those contracted providers who are accepting new patients. The online provider directories will allow consumers/patients to have the most current and accurate provider directory information to assist with selecting participating plan providers when seeking treatment.

Failure to update provider demographics or confirm the accuracy of provider practice information within 30 days can delay reimbursement on fee-for-service payment up to one calendar month. For providers participating in capitated payer contracts, the plan can delay up to 50 percent of the next scheduled capitated payment for up to one calendar month.

Plans are required to update their provider directories every six months, or more frequently should federal laws indicate otherwise.

Revised contracts between plans and providers shall include a requirement that the provider inform the plan within five business days when the provider is no longer accepting new patients, or, if the provider is currently accepting new patients when they had previously not accepted new patients.

In the event that a doctor who is not accepting new patients is contacted by a consumer seeking to become a new patient, the provider shall direct the consumer to the plan for additional assistance in finding a provider and to the plan's regulator to report any inaccuracy with the plan's directory or directories.

To ensure compliance with SB 137, doctors are encouraged to diligently monitor incoming correspondence from the plans for which they are contracted.  It will be imperative that staff responsible for phones, email and faxes are aware of the requirements and are prepared for the inquiries. It is also important that practices respond in a timely manner and are accurate in the responses given.

CPMA Members can find tips to help comply with SB 137 here