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How Network by HealthStream Helps Health Plans Comply with Key Healthcare Laws and Accrediting Bodies

October 21, 2024
October 21, 2024

In the ever-evolving healthcare landscape, health plans are tasked with delivering quality care and navigating a complex regulatory environment in which effective Provider Data Management (PDM) plays a key role. Several critical laws, including the Affordable Care Act (ACA), The No Surprises Act (NSA), and the Consolidated Appropriations Act (CAA), both govern and necessitate how and why PDM has risen in such rapid prominence over the last several years. In addition, accrediting bodies such as the National Committee on Healthcare Quality (NCQA) and Utilization Review Accreditation Commission (URAC) play another critical role in setting policies and procedures for this crucial function. The following article will demonstrate how Network by HealthStream® supports adherence to these laws and standards, thereby contributing to a more reliable and transparent healthcare system.


Legislation

1. The Affordable Care Act (ACA)

Overview: Enacted in 2010, the ACA includes provisions that impact PDM practices, particularly concerning network adequacy and quality of care.

Network by HealthStream Impact:


  • Network Adequacy: The ACA requires health plans to maintain adequate provider networks based on the demographic profile of the specific geography the health plan is trying to serve. Our simple Network Adequacy tool can quickly compare how many primary and sub-specialists you have vs. how many you need to meet demand.
  • Quality Reporting: Health plans that provide coverage under Medicare Advantage (Part C) or Medicaid Managed Care are required by Centers for Medicare & Medicaid Services (CMS) regulations to ensure the quality of care their network providers provide. This may include site surveys, audits, or other evaluations to ensure compliance with CMS quality standards. Our checklist functionality can notate and document the periodic site surveys that must be performed to ensure compliance.

2. The No Surprises Act (NSA)

Overview: Effective from January 1, 2022, this act aims to protect patients from unexpected medical bills, mainly from out-of-network providers.

Network by HealthStream Impact:


  • Provider Data Accuracy: The NSA contains provisions aimed at protecting patients from surprise medical bills, which can occur when they receive care from out-of-network providers, even when they visit in-network providers. Network by HealthStream helps support these provisions by ensuring the provider’s network status is clear and enrollment in specific plan products is properly aligned. This reduces the likelihood of patients inadvertently receiving out-of-network care, which is a key concern addressed by the NSA.
  • Provider Directory Support: As the downstream system of record, Network by HealthStream helps health plans maintain accurate and up-to-date public-facing provider directories with demographic, education/training, location, and plan participation information through our Connect API.

3. The False Claims Act (FCA)

Overview: This act, revised by Congress in 1986, addresses fraud and abuse in federal healthcare programs.

Network by HealthStream Impact:


  • Fraud Prevention: Network by HealthStream helps prevent fraud by ensuring that only qualified and properly vetted providers participate in health plans through various verification automation functionality. Our software leverages integrations with almost 4,000 primary sources, including state licensure boards, education institutions, fellowship and residency programs, etc. This reduces the risk of fraudulent claims and supports compliance with the FCA.
  • Sanction/Exclusion Monitoring: Network by HealthStream helps health plans adhere to these standards by checking all primary federal and state sanction/exclusion sources such as OIG/SAM, state-based opt-out lists, and the Social Security Death Master File.

4. Consolidated Appropriations Act (CAA)

Overview: This act, adopted in 2021, is a comprehensive piece of legislation that addresses areas like surprise billing, transparency, and insurance.

Network by HealthStream Impact:


  • Contract Management: Network by HealthStream untangles the complex relationship between health plan products, providers, and physical location, which reduces the risk of patients receiving out-of-network care unexpectedly using our Contract Management feature.
  • Transparency Requirements: Network by HealthStream supports the CAA’s transparency initiatives by ensuring that healthcare providers and providers meet specific qualifications and are appropriately licensed. This transparency in provider qualifications helps patients make informed decisions about their care and contributes to the overall integrity of the healthcare system.

Accrediting Bodies

National Committee on Healthcare Quality (NCQA)

Formed in 1990 as an independent non-profit, NCQA has been at the forefront of healthcare quality standards for years. Prompted by the rise in managed care utilization, which introduced patients to new types of care providers, the need for standardized quality measures across the healthcare spectrum was born. Now, in the present day, the quality standards that they’ve rolled out, such as The Healthcare Effectiveness Data and Information Set (HEDIS) and Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS), are household names. Because the verification and validation of provider data are often considered to be the front lines for patient safety, NCQA has long been the standard accrediting and certifying body on a healthcare organization’s (providers and payors) credentialing practices, looking at everything from provider rights, committee review, cycle lengths, delegation agreements, audit procedures, and data governance/backup.

Utilization Review Accreditation Commission (URAC)

In 1990, URAC was also formed as an independent non-profit, providing accreditation, certification, and measurement programs for a wide range of healthcare organizations. It was initially established to improve utilization review processes, which assess the necessity and efficiency of healthcare services provided to patients. While URAC is used less frequently than NCQA for accrediting health plan credentialing practices, it is still an important accreditation body. It is preferred in certain situations, particularly when a health plan emphasizes operational flexibility and specialized services. URAC’s standards may be more attractive for plans focusing on or offering more niche services to their members, such as:


  • Telehealth
  • Digital Health services
  • Pharmacy benefit management

Regardless of if you’re using NCQA or URAC as your accrediting body, Network by HealthStream offers the industry's only network relationship management (NRM) system. Seed your database with your provider’s data from national sources, leverage our industry-leading Primary Source Verification (PSV) tools, and continuously stream updated provider data to all corners of your operation.

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