CMS Considers National Directory of Healthcare Providers and Services

In its latest effort to increase transparency and improve patients’ access to information about their health care providers, the U.S. Department of Health and Human Services Centers for Medicare & Medicaid Services (CMS) has released a request for Information (RFI) on October 7, 2022, seeking feedback on the creation of a national provider directory for use by patients, regulators and insurers.

According to the announcement, the RFI was prompted by inefficiencies resulting from “the fragmentation of current provider directories” maintained by providers, insurers and/or third-party sources that CMS says could be remedied by a provider directory. federal containing “digital contact information containing the most accurate, up-to-date, and validated . . . data in a publicly available index.

The stated purpose of the RFI is to examine the feasibility and requirements of a proposed national directory of healthcare providers and services (NDH). Responses to the RFI are expected by December 6, 2022 and stakeholder feedback is already being submitted.

Potential impacts of NDH

The RFI aims to gather information on the viability of a centralized, streamlined, and audited directory to address the challenges of availability and accuracy of health care provider data. The CMS seems likely to require all vendors to participate in the directory, as the RFI is not discussing any opt-out options from the initiative. According to CMS, the NDH will impact health care delivery in at least three ways: (1) potential reduction in administrative costs; (2) improving the accuracy and scope of supplier directories; and (3) centralized support for patients choosing a provider.

  • Economic savings: The Council for Affordable Quality Healthcare (CAQH) estimated in 2019 that medical practices collectively spend $2.76 billion each year on directory maintenance, or about $998.84 per month per practice. As noted in the RFI, CAQH estimated that moving directory data to a single simplified platform would save the average medical practice approximately $4,746 per year, or approximately $1.1 billion in national collective economies.
  • Consolidated supplier directory management and use: Although CMS leads the proposed directory, patients, providers and payers will be able to use modern interoperable technology through the use of an application programming interface (API). This technology would, for example, allow patients to locate providers through the apps of their choice, providers to submit prior authorization requests to payers, and payers to update their own directories from the NDH. For example, if a supplier moves, they currently need to update several systems and databases to accommodate their new office location, including the National Plan and Supplier Listing System (NPPES) and the Provider Enrollment, Chain, and Ownership (PECOS), among other public or private systems. If implemented, NDH will allow the provider to update their new location only once through a single entry point, thereby mitigating the risk of inaccurate information across different systems.
  • Access to the user directory: Currently, patients choosing a provider must manually navigate a series of fragmented systems operated by various entities to collect and compare provider information. In contrast, a national provider directory would provide a one-stop shop for understanding health care provider availability—a process complicated by the frequent inaccuracies in private provider directories. This can better inform patients about insurance choice, provider choice, and the ability to make informed choices in general. Patients can also benefit from consumer health apps that combine NDH data with cost and outcome information, to provide patients with a more complete understanding of their choice to enroll in a given plan or get treated by a given provider.

Interaction with other CMS interoperability regulations

The RFI seeks to gather information consistent with CMS’s efforts to facilitate interoperability and access to health information. Under the Consolidated Appropriations Act 2021, those offering group or individual health insurance coverage must publish a directory of health care providers and their facilities. Group health plans and health insurance issuers are also required to regularly verify a provider’s address, name, specialty, and phone numbers. The law further protects consumers against misidentifying a network supplier or facility in its directory by supplying items or services as if supplied by a network supplier and by applying deductible maximums or disbursed in the same way. . This RFI gathers information to support activities consistent with these statutory objectives.

CMS conducts annual reviews to compare the accuracy of a Covered Plan’s provider machine-readable data files with online provider directories and other data sources such as NPPES. In its most recent review for plan years 2017-2021, CMS determined that only 28% of provider information provided by plans matched NPPES registry information for those providers. The RFI is considering a method to improve the accuracy of plan data: real-time access to the most up-to-date information in a central repository managed by the federal government.

An NDH would also complement federal efforts to establish “a universal floor of interoperability” through the Trusted Exchange and Common Agreement (TEFCA) Framework. We’ve previously covered the pending framework on this blog, including its potential to remove barriers to patients using their own healthcare data. NDH and TEFCA are likely to implement Fast Healthcare Interoperability Resources interfaces, a flexible technology for the standardized exchange of health information. While TEFCA and NDH are still ongoing, these parallel efforts, using similar technology standards, reflect an increasingly cohesive federal approach to ensuring patients can access and benefit from their healthcare data.

Keys to effective feedback

CMS invites feedback on three specific components of a potential supplier directory:

  • What technical or policy prerequisites should be met before developing an NDH?
  • What specific risks or challenges should be anticipated throughout the system development lifecycle of an NDH, and how can these risks and challenges be minimized?
  • What are the most promising efforts that exist to date to address the healthcare repertoire challenges, and how might the CMS best incorporate these efforts into the requirements of an NDH? What gaps remain that are not being filled by existing efforts?

Calvin W. Soper