Q—What do doctors need to know?

A—Doctors of optometry should be aware that under the No Surprises Act (NSA), health plans must maintain an accurate provider database website, and verify the accuracy of the information at least every 90 days. However, this does not preempt any state laws or regulations that require provider directories to be updated more frequently than 90 days. The health plan must implement a process for removing providers who fail to verify their directory data. When the health plan receives new or revised information from a provider, it must update the public directory within two business days.

Doctors and other health care facilities—or the health plan—may be required to refund excess patient payments when the patient has inadvertently received out-of-network care and been charged in excess of in-network cost sharing due to inaccurate provider directory information.

Source: govinfo.gov/content/pkg/USCODE-2020-title42/pdf/USCODE-2020-title42-chap6A-subchapXXV-partD-sec300gg-115.pdf

Source: cms.gov/files/document/a274577-1b-training-2nsa-disclosure-continuity-care-directoriesfinal-508.pdf

Q—Does this apply only to certain facilities or to all health care providers, including doctors of optometry?

A–The Centers for Medicare & Medicaid Services (CMS) expects to issue regulations for the NSA provider directory provisions at some point in 2022. Meanwhile, the agency states that the law does not exempt any categories of providers or facilities. The term “provider” includes physicians and other providers acting within the scope of your state license or certification.

Source: cms.gov/files/document/a274577-1b-training-2nsa-disclosure-continuity-care-directoriesfinal-508.pdf

Q—What do doctors need to do?

A—Doctors of optometry should be aware that health plans will actively seek to verify provider directory information. If you don’t respond, then the plan is obligated to remove you from the directory. Doctors also have obligations: You must submit your provider directory information when you contract with a health plan, when you terminate your contract, and when there are material changes to your directory information. You also have the right to include terms in your contracts with health plans that require the plan to remove you from the provider directory when you terminate your contract, and for the plan to bear financial responsibility for providing inaccurate network status information to patients.

Source: cms.gov/files/document/a274577-1b-training-2nsa-disclosure-continuity-care-directoriesfinal-508.pdf

Q—To whom does the law apply?

A—The requirement for health plans to have accurate directories applies to “group health plans” (primarily employer coverage, self-insured or fully insured) and “health insurance issuers” (primarily individual market plans and group health insurance). The requirements also apply to federal employee plans. It does not apply to Medicare, Medicaid, TRICARE, Indian Health Services or Veterans health care.

Sources: govinfo.gov/content/pkg/USCODE-2020-title42/pdf/USCODE-2020-title42-chap6A-subchapXXV-partD-sec300gg-115.pdf


Q—What about vision plans?

A—Federal “excepted benefits” such as standalone vision plans are exempt from these requirements. However, when managed vision care companies administer networks and provider contracts for health plans, the AOA believes the law would still apply to the health plan and that the vision plan might seek to verify provider directory information on behalf of the health plan.

Source: cms.gov/files/document/a274577-1b-training-2nsa-disclosure-continuity-care-directoriesfinal-508.pdf

Q—Is there a deadline?

A – These provisions of the law took effect on Jan. 1, 2022, and apply to plan years that begin on or after that date. Health plans are expected to work with health plans “to make good faith efforts” to ensure the timely provision of directory information. Until regulations are published, the federal government will impose enforcement discretion on plans who are not in compliance with the provider directory provisions.

Source: cms.gov/files/document/a274577-1b-training-2nsa-disclosure-continuity-care-directoriesfinal-508.pdf

Q—Why is this related to balance billing and the No Surprises Act?

A—The new law and its protections apply primarily to out-of-network health care services. Patients need accurate provider directories so they know in advance whether the doctor they choose is in network.

Source: cms.gov/files/document/high-level-overview-provider-requirements.pdf

Q—Does the law require me to respond to verification requests or be kicked out of networks?

A—The law requires health plans to keep their provider directories current.  Health plans must implement a process to remove you from the network if you don’t validate your information.

Source: govinfo.gov/content/pkg/USCODE-2020-title42/pdf/USCODE-2020-title42-chap6A-subchapXXV-partD-sec300gg-115.pdf

Q—What type of information must be in the provider directory?

A—The health plan provider directory must include the name, address, specialty, telephone number, and digital contact information of each health care provider or health care facility with which the health plan has a contract for furnishing items and services.

Source: .govinfo.gov/content/pkg/USCODE-2020-title42/pdf/USCODE-2020-title42-chap6A-subchapXXV-partD-sec300gg-115.pdf

 Q—What is 'digital contact information'?

A—Future regulations will better address this question, but generally digital contact information is a health information exchange “endpoint” such as your direct message address that allows health care providers to send authenticated, encrypted health information directly to trusted recipients securely over the internet. Endpoints also include FHIR server URL, or query endpoint.

Source: cms.gov/outreach-and-educationoutreachffsprovpartprogprovider-partnership-email-archive/2021-10-07-mlnc#_Toc84424561

Q—What are 'endpoints'?

A—Future regulations will better address this question, but generally endpoints are a direct message address (or related URL), not a personal email address. Endpoints provide a simple and secure way for participants to send authenticated, encrypted health information directly to known, trusted recipients over the internet. Endpoints can be used to exchange health information between health care entities (primary care physicians, specialists, hospitals, labs, etc.). Endpoints also include FHIR server URL, or query endpoint.

Source: nppes.cms.hhs.gov/webhelp/nppeshelp/HEALTH%20INFORMATION%20EXCHANGE.html

Q—Weren’t health plans supposed to have accurate directories before?

A—Many states had laws or regulations that contained provider directory requirements priors to the enactment of the No Surprises Act. Also, insurance companies who sell Medicare Advantage (MA) plans were required to keep their MA provider directories current. However, many were inaccurate. Commercial health plans did not have a specific obligation to maintain accurate provider directories, but many plans already require doctors and facilities to update the plan with accurate directory information.

Source: beonbrand.getbynder.com/m/2ecc64c61941e3d4/original/CMS-Provider-directory-memo.pdf

Q—What if there is a related law in my state? Do I have to follow both?

A—State laws are preempted only when those laws impose a requirement that prevents the application of the No Surprises Act. For example, if a state has a law or regulation that requires provider directories to be updated monthly, it will remain applicable. If a state law or regulation requires directory updates less frequently than 90 days, the No Surprises Act requirements will supersede it. 




Q—Will I get these requests from health and vision plans? From CAQH? From the federal government?

A—You are likely to hear from health plans and contractors who provide validation services for health plans. You might also receive requests from managed vision care companies administering a network for a health plan.

Source: AOA member experiences.

QWhat is the No Surprises Act?

AThe No Surprises Act is Title I of Division BB of the Consolidated Appropriations Act, 2021 (CAA). The law amended title XXVII of the Public Health Service Act (PHSA) to add a new Part E.

Source: cms.gov/files/document/high-level-overview-provider-requirements.pdf

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