A Health Plan’s Guide to Navigating the REAL Health Providers Act

A Health Plan’s Guide to Navigating the REAL Health Providers Act

The pressure on health plans to comply with regulations around provider data accuracy is growing. Recent legislation like the No Surprises Act and many state-level regulations (for example, New York’s Out-of-Network Law and Illinois’ Network Adequacy and Transparency Act) aim to protect consumers by requiring health plans to update provider information within specific time periods or face fines and penalties if they do not comply. 

In October 2023, a bipartisan group of senators introduced the Requiring Enhanced and Accurate Lists of Health Providers Act (or REAL Health Providers Act), with the goal of improving Medicare Advantage provider directories and reducing ghost networks. If the Act passes, it will go into effect in 2026. With so many regulations for health plans to keep track of, let’s break down the REAL Health Providers Act, what’s included, and how it differs from others.

What is the REAL Health Providers Act? 

The REAL Health Providers Act aims to hold health plans accountable for accurate provider data in directories and reimburse members for any out-of-network expenses incurred by a member seeking care from a provider listed in the directory. There are several components of the bill that support this: 

Provider Directory Requirements

• Medicare Advantage (MA) plans must maintain an accurate provider directory for each MA network-based plan (i.e. almost all MA plans) on a publicly available website. The provider directory must include the following information for all providers contracted with the plan: provider name, provider specialty, contact information, primary office or facility address, availability, accommodations for persons with disability, cultural and linguistic capabilities, and telehealth capabilities.
• At least once every 90 days, MA plans must verify the accuracy of the provider information and update the directory as needed.
• MA plans need to include an indicator in the directory for any provider for whom it cannot verify the accuracy of that provider’s information. 
• If it’s determined that a provider is no longer a participating provider in the plan’s network, the provider must be removed from the directory within 5 business days 

Accountability for Provider Directory Accuracy

• MA plans must guarantee that if a provider is listed as in-network in the provider directory on the date a member makes an appointment, the member is only responsible for the in-network cost-sharing amount, even if the provider is out of network.
• MA plans are obligated to notify members of this cost-sharing protection by the 1st day of the annual election period, include this information in the provider directory for each MA plan under its organization, and in an explanation of benefits.

Provider Directory Accuracy Analysis and Reporting

• MA plans are required to conduct an annual analysis of the accuracy of the provider directory for each network-based plan. The analysis should include provider types with high inaccuracy rates such as providers specializing in mental health and substance use disorder treatment
• MA plans must submit a report with the results of this analysis every year. 
• The Secretary of Health and Human Services will then post accuracy scores from all MA plans in a machine-readable file on the Centers for Medicare & Medicaid Services website. 

How does the bill differ from the No Surprises Act? 

When you think of provider directory compliance and regulations, the No Surprises Act is likely the first that comes to mind. The No Surprises Act (NSA) went into effect in January 2022 and was among the first national regulations to hold health plans accountable for maintaining accurate and updated information about providers in their network. However, the NSA does not apply to Medicare Advantage plans. The REAL Health Providers Act is intended to address that gap and align MA plan directory expectations with those in the NSA.

In terms of requirements set around provider directory accuracy, the REAL Act differs from the NSA in a few primary ways. First, the NSA has a few requirements that are not specified in the REAL Act: (i) the need to update provider information within 2 business days of receipt from a provider; and (ii) the need to respond to a request regarding network status of a provider within 1 business day and to retain that communication for 2 years.

The REAL Act also introduces several new directory requirements that go beyond what’s included in the NSA. The Act stipulates 3 additional data points that must be included in the directory: accommodations for persons with disability, cultural and linguistic capabilities, and telehealth capabilities. There are also new requirements around analyzing directories for accuracy, as touched on above - health plans must conduct and submit an annual analysis of the accuracy of their MA plan directories, which will then be posted on the CMS website, along with all other MA plan accuracy results. 

What can health plans do to get ahead of this new regulation? 

While 2026 may seem far off, it’s less than a year and a half away. With regulatory pressures coming from multiple pieces of legislation on both the federal and state levels, it’s even more pressing for health plans to find a solution quickly. Some health plans have teams dedicated to managing provider data, but this requires hours and hours of manual work. To find a truly scalable solution that will ensure compliance and automate the provider data process, health plans should look to a technology platform. 

Ribbon Provider Data Platform is a flexible, API-first, data management tool that centralizes a health plan’s provider data sources and workflows into one comprehensive platform. Our proprietary machine-learning technology guarantees that provider data received from all sources is standardized, scored for accuracy, enriched, and updated in less than 24 hours, to support compliance with regulatory requirements. Ribbon partners with our health plan partners to determine accuracy goals, align on a plan to achieve those goals, and provide regular reporting on progress, so health plans can easily comply with the Analysis and Reporting component of the REAL Act. 

Learn more about Ribbon Provider Data Platform and our work with leading national health plans below.

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