The national provider directory discussion is clearly focused on the patients and health plans. It focuses on the patients because they’re the consumer of this information and without it, they can’t make educated decisions when buying health insurance. The conversation focuses on health plans because they’re the ones being held accountable for making the information available to consumers. To effectively address this issue, we also need to take a good hard look at things from the providers’ point-of-view. That’s what this episode is all about.
We’ll talk with Bill Barcellona, Sr. VP for Government Affairs at CAPG, which is a national association that represents physician organizations who practice capitated, coordinated care. Bill does an excellent job of sharing the providers point-of-view on the provider directory issue and shows us how provider groups can take the lead on cleaning things up. Bill also tells us about California’s SB-137 and explains how it’s putting pressure on both health plans and provider groups. It’s a fascinating discussion that will expand your understanding of this increasingly complex issue. You’ll learn:
- What is SB-137? (1:20)
- Where do all the provider directory errors come from? (3:19)
- Who’s responsible for provider directory accuracy? Who’s accountable? (5:00)
- What does SB-137 call for specifically? (7:45)
- How have providers responded to the accountability placed on them by SB-137? (11:00)
- What is the SB-137 timeline (12:45)?
- Why can’t health plans pull accurate provider demographics from the claims? (13:25)
- Why is it beneficial to address this problem on the provider side? (17:30)
- How else are providers impacted by this problem? (19:30)
- When should the health plan go directly to the provider for info? When should they go to the group? Why is there a distinction? (20:40)
- How can inaccurate provider directories lead to FTC/anti-trust scrutiny? 24:50
- How is CAPG working with Gaine Solutions (Sanator) to help providers address the issue? (26:45)
- What is the California Provider Directory Collaborative? (30:30)
- Can a California-based solution scale nationally, or are California’s problems unique? (33:00)
- What are the risks associated with a state-wide or nation-wide solution? (34:27)
- How SB-137 and other rules have killed the idea that narrow network details are proprietary information (37:15)
- Defining a public API for master and metadata needed to share information about contracts, networks, products, and providers nationwide.
Or, listen right here:
Prefer to read it? Transcription coming soon!
About Bill Barcellona
Bill Barcellona serves as the Senior Vice President for Government Affairs for CAPG, overseeing state and federal legislative and regulatory activities for the association in Sacramento and Washington, DC. Bill is the former Deputy Director for Plan-Provider Relations for the Department of Managed Health Care in Sacramento. In that capacity, he oversaw health plan operational issues and handled policy matters for the DMHC. Bill has a Masters in Healthcare Administration from the University of Southern California and serves as an adjunct faculty member at USC and also holds a B.A. in political science and a J.D. He enjoys teaching and lecturing across the country on health care management, operations and policy matters. He has practiced law for 28 years in California and prior to his service at the DMHC he spent 16 years at two major law firms in Newport Beach and Sacramento, primarily as a civil litigator. His current legal experience includes general health law matters with an emphasis in Knox-Keene Act and managed care issues.
Bill is a former Judge Pro Tem in the El Dorado County Superior Court and served as an appointed member of the California State Bar Association Insurance Law Committee. He was previously awarded the 2009 Alumnus of the Year by the USC Health Services Administration Alumni Association, and a 2-year term as a board member of the Health and Human Services Privacy and Security Advisory Board. He lives in Folsom, a small town in the foothills of the California Gold Rush. He has been active in the community for over 20 years, serving as a Planning Commissioner for the City of Folsom, chairing bond measure campaigns to build new schools, serving as an officer of the Folsom Economic Development Corporation and in the past as a Director of the Folsom Chamber of Commerce. Bill currently serves as a member of the USC Price School Health Advisory Board.
CAPG is the leading association in the country representing physician organizations practicing capitated, coordinated care. Their membership currently comprises close to 300 multispecialty medical groups and independent practice associations (IPAs) across 42 states, the District of Columbia, and Puerto Rico.
Register now for the CAPG Annual Conference 2017 – June 22-24 in San Diego, CA – CAPG’s Annual Conference attracts national industry leaders from top medical groups, independent practice associations, hospitals, health plans, and government who come together to learn about the latest and greatest in capitated, coordinated healthcare.
Also mentioned on the show:
California Provider Directory Collaborative – The California Provider Directory Collaborative Community of Practice is an online forum dedicated to supporting a statewide dialogue on critical provider data and directory issues and to inform regulators as they implement SB 137. Please contact us at ProviderDirectory@manatt.com if you have any questions or would like to learn more.
CAPG White Paper: Provider Directories – Driving Accurate Lists for Consumers
Sanator Provider Registry by Gaine Solutions
California’s SB-137, which took effect on July 1, 2017, is one of the most aggressive pieces of legislation addressing the provider directory issue at the state level. It also became the first legislation that holds providers directly accountable for reviewing and updating their records with the health plan. If providers fail to share updates in a timely manner then health plans can remove them from the directory, withhold full or partial payments for up to 1-month (the so-called “hammer provision”), or even terminate their contract. This bill has real teeth and it’s gotten people’s attention.
About the Provider Directory Podcast Series
This episode is part of our ongoing Provider Directory series that aims to dissect the issue from all perspectives, including provider, payer, patient, and regulator. Our goal is to help facilitate an expanded national conversation that drives us towards an open, collaborative industry solution.
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