Everyone knows the major reasons why professionals don’t contract with insurance. But then there are also a thousand things, like directory attestations, that make taking insurance more difficult than it should be. I saw this missive in my email recently.
Awww. How touching.
What insurers fail to understand is that they’ve set up a “death by 1,000 cuts” environment.
- Directory Attestations
- EDI enrollment
- Reassociation of EOB/ERA and EFT/paper checks
- Virtual credit cards
- Portals & passwords
- Coordination of benefits
- Duplication of credentialing tasks
Or maybe they understand all too well. Any one of these by themselves is annoying enough. Together with low reimbursement, audits/clawbacks, and ever-increasing documentation requirements, you have a perfect storm of therapists not contracting with insurance panels. Or leaving them.
In the Death by 1,000 Cuts series, I’ll focus on each of the above. How does the system as it exists today have the following effects?
- Insurers are systematically devolving what is/should be their responsibility, onto healthcare professionals.
- In some instances, insurers are setting it up so that independent billers and/or credentialing companies, can’t function effectively in their support roles.
- The negative consequences to practices in terms of time, finances, and stress.
If you have to take insurance, what you can do to maintain your practice sanity?
Let’s look at a recent situation I encountered.
Department of Redundancy department, with a dash of techno-insanity
Regence is a multi-state Blue payer owned by Cambia, serving Oregon, Utah, parts of Idaho, and parts of Washington. Their credentialing uses CAQH. Like an ever-increasing number of Blues these days, they’re Availity-enabled. Anyone with an Availity account, even billers, constantly receives emails threatening dire consequences if you don’t do directory attestations. It’s overwhelming!
Clinicians are required to attest every quarter under CAQH. Availity requires directory attestation every 90 days. On top of that, Regence sends participating practices a secure email, with complex instructions to download a spreadsheet with multiple columns, fill it out in a certain way only, and then re-upload it. Every 90 days. Despite also attesting to CAQH and Availity.
Barriers? Sure, I can think of a few.
- Lack of compatible technology. Not everyone has Microsoft Office.
- Lack of comfort with technology. Many behavioral health clinicians practice competently into their 70’s. I’ve even worked with 80-somethings. Is it fair to expect elders who didn’t grow up with technology to navigate all this?
- Even younger clinicians may not be comfortable with technology. After all, they chose a people-oriented profession.
- Lack of time! In between sessions, clinicians have a few other things to do.
- Not understanding why attestations on CAQH and Availity aren’t sufficient. (I don’t understand it, either!)
Lest anyone think I’m just picking on Regence…I’m not. What they do is repeated a thousand times over, nationally, by other payers. Some payers use their proprietary portals, rather than spreadsheets, but the main point is: how many times, ways, and in how many places, should providers be required to confirm the same basic information?
Devolution of payer responsibility
Payers blame the government: “It’s not OUR fault, the government passed the No Surprises Act. We’re just complying with the law.”
What does the No Surprises Act really say about Directory Attestation?
No Surprises isn’t entirely to blame. Directory attestations began in 2016, when CMS was authorized to fine Medicare Advantage plans up to $25,000 per beneficiary for too many directory errors. In this article from almost a decade ago, a payer representative was quoted as saying “oftentimes providers aren’t cooperative and won’t call insurers back.”
Ms. Payer Representative, would you call back if you received a voice mail from someone with a hard-to-understand accent, asking for personal information? When you didn’t know who they’re representing or why they’re calling? In a culture where phishing is attempted daily, you’re going to blame providers for being careful?
So attestations were a thing 6 years before the No Surprises Act (NSA). But they’re mandatory as of January 1 2022, right?
The NSA requires that insurers maintain adequate directories, yes. Here’s the text of the actual law (click to be taken to the statute).
Where’s the word “attestation?” I don’t see it…do you?! The law only says insurance plans need to verify and update their directories. It doesn’t say anything about providers needing to attest on Availity every 90 days.
No one disagrees that accurate provider directories are a necessity. But this system of multiple attestations hasn’t proven effective. Does anyone question why, or do they just mandate another attestation? Payers complain: “why don’t we get provider cooperation? It only takes 5 minutes!”
Maybe sometimes. But portal-based attestations require logging in. Does the clinician use the portal the other 89 days? What if they don’t do their own billing, or bill through an EHR? They might have to update their password and go through the portal’s multi-factor authentication. No, I’m not criticizing the need for stringent cybersecurity rules. But lack of technical literacy can be a barrier. So can the frustrations of logging in, changing passwords, resetting defunct accounts, etc. So NO, attesting doesn’t necessarily only take 5 minutes.
In the above example, it’s CAQH, Availity, and Regence. But there’s also United (Provider Express), Cigna (Evernorth portal), Magellan, and many other payer-specific portals. Each payer requiring attestations on its own portal represents more non-billable time on the part of the practice. So at least in part, it appears that the systems of attestation in common use today represent payers passing on their legal responsibility to providers.
How many attestations does it take to maintain an accurate directory?
Look at paragraph 2c in the law quoted above. PAYERS are responsible for updating directory databases within 2 business days of receiving provider updates. How often does that happen?!
I enjoy pointing this out to payers who don’t process demographic updates timely and then blame clinicians. Clearly, not all parts of the No Surprises Act were created equal.
There’s more. The article from 2015 mentioned above also describes payer plans to use CAQH as a central place to obtain directory data. Why didn’t that happen? Did CAQH charge too much?
Radical idea: if CAQH was the only place where all healthcare providers had to go to update & attest, and payers actually obtained data there, we might achieve cooperation and more accurate directories.
Preventing billers/credentialers from helping effectively
Some of the “thousand cuts” I’ll be describing in this blog series are guilty of hamstringing billers and credentialers. Attestations, though, can usually be done by administrative staff – if they have portal access. Which isn’t always easy or quick to obtain.
But administrative staff has to be paid. Why must practices shoulder the costs of directory accuracy, rather than the payers?
Negative consequences to practices
If time is money, then additional burdens from payers which require significant time, without a compensatory reimbursement rate increase, is an effective rate decrease. More work for the same money means less earned per hour. Or, if the choice is made to hire help to complete a payer-required task, that’s an extra expense.
It’s not rocket science, and we’ll see this dynamic repeated over and over again in the Death by 1,000 Cuts blog series.
Healthcare professionals’ time is important also!
How can you take care of yourself and your practice?
There’s no avoiding attestations, but there are a few ways to protect your sanity and profitability.
- Schedule time once every 90 days to do all your attestations together, during time you’re already devoting to administrative work.
- During this time, there’s a chance you’ll be using those portals for something else – so attest then.
- Reacting hastily to urgent-sounding emails increases stress levels. Don’t be fooled by the tone of those email blasts.
- Nothing awful is going to happen if you’re a few days late. While it’s better to be on time, life happens. Take care of yourself and your clients first.
- Don’t be too late though. After a few months’ non-response, payers will sometimes remove non-responders from networks – not just the directories. Getting re-connected isn’t a fun process, for you or your clients.
- Use a password management vault to store passwords.
- If you’re not taking new clients from a specific payer, mark yourself as “not accepting new patients.”
- Payers often send surveys. Don’t be afraid to state your opinion that if they used CAQH for attestations, the process would be improved for everyone. (They might ignore it, but what if everyone said the same thing?)
- If the tech gives you problems, print your updated CAQH profile and send it to the payer who refuses to use CAQH. Remember, there’s nothing in the law specifying how you’re mandated to attest.
- Actively communicate with your biller or credentialing service around who’s responsible for attestations.
- Be clear about cost and turnaround time expectations.
- Provide them with the tools (notifications and online access) that they need to do the attestations for you.
And, if you get dropped from the network … remember that No Surprises also mandates that your clients are to be given “continuity of care” benefits at the in-network reimbursement level. I’ve been seeing cases lately where payers are … forgetting … about that part of the law.
Need help with practice management, billing issues, or credentialing problems? You don’t have to go it alone. Schedule a consultation and get help!
