I recently received this lovely email demonstrating Availity’s fear-mongering attempts to threaten clinicians into attesting to the correctness of their practice profiles. (They still haven’t figured out that I’m not a provider…!)
I have no objection whatever to maintaining correct insurance provider directories. And clinicians absolutely should keep their profiles current. I do, however, object to Availity’s fear-mongering.
Those last two consequences do not, in fact, originate with CMS. If they even exist at all.
To date, I know of no instances where either of these consequences has ever occurred. I seriously doubt they could.
Why?
Payment Delay
49 out of 50 states currently have “prompt-payment” laws directing health plans to pay “clean” claims within a certain timeframe (most usually, 30 days for electronically-submitted claims). These laws specify that insurers are to pay interest on all claims paid late. In mental health, we typically don’t worry much about interest, because a few days late on the low insurance reimbursement amounts to maybe 10 cents. But a pattern of delaying claims payment using the excuse of directory non-attestation would certainly catch the attention of state regulators.
I don’t know of any state or federal regulation which allows for the requirements of “prompt-payment” laws to be set aside if a healthcare professional fails to complete a directory attestation. Timely or otherwise.
I invite Availity to show me the citation or source for these assertions. If CMS does require such drastic consequences for non-attestation, I’ll amend this blog.
Transferring members to a “compliant” provider
Really? I can come up with several reasons why Availity’s fear-mongering threats don’t actually happen.
- Transferring patients to a “compliant” professional would constitute direct interference with clinical care. Insurance companies routinely use the excuse that “we’re not directing your care, we’re only saying whether we’ll pay for it.”
- There have already been multiple initiatives to change the law so that insurers could be held legally liable for harm caused by their medical or treatment decisions. Here’s a link to one such federal bill, from back in 2003. I seriously doubt insurance companies are going to take any actions that would strengthen arguments in favor of finally enacting such laws.
- Can you imagine the public outcry? American insurance companies are aware of how negatively they’re perceived. Transferring people’s care would only make the public’s negative opinions worse. Much worse.
- Unless the “compliant provider” was directly owned by the insurer or had insurer investment, what would transferring patients actually even accomplish, from a financial standpoint? (Lawyers, on the other hand, would get some serious job security!)
- In addition to similar laws in 42 states, the federal No Surprises Act grants clear protections when a practice or healthcare professional is terminated from a panel, or leaves voluntarily. These laws mandate that clients have a legal right to receive continuity of care benefits at the in-network level for a period of time after the network termination. Payers are subject to enforcement actions if they breach these rights. So, yanking a client from a “non-compliant” to a “compliant” clinician seems like a clear violation (in my non-legal opinion).
- Want more information about client rights if you end an insurance contract? I offer several useful guides for clinicians who want to Leave Insurance Behind!
What about the first threat? Can they remove me from the directory?
They can, yes. But before you freak out, directory removal isn’t as clear-cut as Availity’s fear-mongering statement makes it sound. Payers don’t automatically remove you on day 91 for not attesting on Availity.
What Availity is doing, is overstating Section 116, 42 USC §300gg-115(a)(2)(A-B) of the federal No Surprises Act. The exact language of the law states,
The verification process described in this paragraph is, with respect to a group health plan or a health insurance issuer offering group or individual health insurance coverage, a process—
(A) under which, not less frequently than once every 90 days, such plan or such issuer (as applicable) verifies and updates the provider directory information … of such plan or issuer of each health care provider and health care facility included in such database;B) that establishes a procedure for the removal of such a provider or facility with respect to which such plan or issuer has been unable to verify such information during a period specified by the plan or issuer;
In English: the law is saying that directory verification is the PAYER’s responsibility – not the provider’s. And that the payer “establishes a procedure for removal” of directory entries that can’t be verified. Establishing a procedure ≠ automatic removal. That’s rather a large leap for Availity to make.
Then there are the practicalities. Removing non-attesters on Day 91 would take more staff than insurance companies are willing to employ, given their 2026 pattern of eliminating jobs.
Besides, network adequacy is always an issue. So if insurance companies were to hire the necessary staff, wouldn’t those employees be better utilized to verify the directory information instead of removing names?
Did you notice how the payer’s legal responsibility has now, in the hands of Availity’s fear-mongering, suddenly become yours? Personally, I think the term “gaslighting” seems appropriate to describe Availity’s remarkable 180-degree deviation from what the law actually says about who bears responsibility for correct directory listings.
Again…I’m not saying don’t attest or don’t update your profile. What I’m saying is DON’T WORRY in response to Availity’s fear-mongering.
So what’s the goal of Availity’s fear-mongering?
Until or unless I can speak with the decision-makers at Availity, what I say here is just a guess, but as a long-time industry observer, I think my speculation will come close.
The reason is the almighty dollar. (Isn’t that the #1 reason any corporation acts the way it does!?)
Availity sells their Provider Data Management (PDM) utility to a large number of insurers. They promise they’ll improve payers’ directory accuracy, stating that “70% of U.S. providers actively attest through Availity PDM, and directories built on Availity data show a 75% accuracy rating.”
Availity might believe that in order to deliver on their promises, a bit of fear-mongering pressure will get more providers to comply. After all, back when I was in school, 75% was only a “C” grade.
“I attest regularly and even after several years, XYZ Insurance STILL has my information wrong!”
Yup. Availity just delivers your information to the payers. It can’t control what payers DO with it.
Claims payment systems and the public-facing insurance network directories are generally fed by different data platforms. You notify a payer that you have a new address, and the provider data management department at the payer (eventually) updates the claims system, but forgets to update the directory system (or can’t access it because it belongs to a different team.) Meanwhile, you update Availity every 90 days or thereabouts, and you think all is well. Until a client comes to you 3 years later, asking why you’re not at the address listed in the directory.
Ultimately, compliance with the directory portion of the No Surprises Act rests with payers, despite Availity’s fear-mongering. The above quote from the law has a section (C), which says
(C) provides for the update of such database within 2 business days of such plan or issuer receiving from such a provider or facility information …
I enjoy pointing this proviso out to payers when requesting that they actually make the changes clinicians have submitted repeatedly. It’s very satisfying to watch them leap to comply after being ignored for years on end.
By all means, please attest. Keep profiles current. But don’t let Availity’s fear-mongering gaslight you into accepting responsibility that isn’t legally yours, for functions that you can’t control.
Having trouble with Provider Data Management issues, whether through Availity or with a payer? I can help.
