HIT Consultant – Read More

The proposed Requiring Enhanced and Accurate Lists (REAL) Health Providers Act—also referred to as the RHP Act—recently signed and expected to take effect for plan year 2028, represents a significant shift in how healthcare providers are regulated, credentialed, and represented to Medicare Advantage members.

The proposed requirements aim to provide health plan members with greater transparency, accessibility, and accuracy within provider directories in their member portals. Payers will need to implement these new requirements while maintaining compliance and a high standard of consumer-centric service. As regulatory pressure intensifies, health plans must remain agile by modernizing processes and embracing technology so they can deliver value without disruptions as these new proposed regulations are enacted into law and subsequently enforced.

What the RHP Act regulations entail

The RHP Act will raise the bar for provider data accuracy, transparency, and timeliness. Under the RHP Act, payers will face financial sanctions for inaccurate or inconsistent directory data. New requirements include mandatory real-time updates to provider information within 48 hours of changes and the prompt removal of out-of-network providers. The RHP Act also includes standardized credentialing processes and more user-friendly directory formats for a more member-centric experience.

Increased directory analysis and verification will be needed to keep up with these requirements and avoid fines. This will be difficult for payers that have only had fragmented systems or faulty technology available to manage their data. It will require payers to rethink data management and accelerate efforts to modernize their infrastructure and maintain compliance. 

The RHP Act aims to eliminate ghost networks, where providers remain listed as in-network when they are no longer active or accepting new patients, or otherwise unavailable. The legislation seeks to ensure that consumers can find accurate information and connect with providers efficiently and reliably.

The impact on payers

Payers should be actively preparing for operational and compliance pressures resulting from the proposed legislation. Fragmented systems may lead to inaccurate data, which could then result in non-compliance and sanctions. Organizations need to implement structured, efficient workflows that track provider status and ensure data accuracy. Consolidating systems can help ensure that data is accurate and constantly up to date. 

Further, manual processes can be difficult to manage and maintain. Managing provider networks requires a strong data infrastructure and systems in place to meet the new time requirements. Human error, as well as time management, may act as barriers to implementing these changes. The requirement to update directory information within 48 hours and maintain ongoing verification could strain manual or fragmented workflows. 

Payers face expanded compliance risk, both due to the financial penalties associated with the proposed legislation, as well as the potential for reputational harm and a decrease in member trust. For many payers, compliance under the RHP Act will require a system-wide shift in how they manage, verify and publish provider network data.

Strategic navigation of the RHP Acts’s new guidance

Given the potential impact, payers should consider a proactive and strategic approach to preparing for the regulatory changes and navigating the transformation smoothly.

The ability to adapt quickly will help organizations in the long run, not just in maintaining compliance but also in maintaining a strong reputation rooted in member trust and transparency.

Organizations should be evaluating current systems and identifying areas for improvement. A critical first step is assessing current workflows to understand how provider information is being collected and processed and where inconsistencies arise. Going forward, organizations should regularly evaluate their processes and technology to ensure smooth operations, moving away from periodic verification cycles to a continuous, rapid review structure.

Establishing clear governance is also important to define which teams are responsible for tracking, validating and updating changes in provider data, so directories stay up to date. Directories must contain complete, member-relevant information, including information on specialties, practice locations, and availability, to avoid ghost network designations.

Finally, payers should maintain detailed audit trails and documentation of directory updates. This helps to reduce compliance risk and create a more reliable, member-centered provider data model.

Where technology can support teams and standardize efficiency

As the RHP Act sets tighter standards, technology will be a necessary tool to help payers maintain compliance. Provider data management tools are widely used across the payer community to address challenges in maintaining provider directories, and the proper infrastructure can consolidate data into a single source of truth.

Adding automation to these necessary workflows can streamline capabilities and ensure real-time updates to provider status, practice details and credentials, pushing updates to directories swiftly, addressing a key provision of the RHP Act. This eliminates the need for manual entry, which comes with the potential for human error and is extremely time-consuming for staff and would be difficult to maintain with new timeline requirements. 

Technology also offers the opportunity for increased analytics and AI implementation to make recommendations to streamline and build checks directly into workflows that ensure compliance and identify data discrepancies early on to maintain documentation ahead of audits. Automated platforms also offer more user-friendly processes to keep up with the RHP Act standards for members. These functions improve information accessibility and empower members to navigate platforms with ease. With the proper foundation in place, payers can confidently present directories that are accurate and updated, ultimately improving member trust, reducing friction, and maintaining the RHP Act standards.

With the help of automation and data tools, organizations can transform provider data management from a reactive, time-consuming operation into a proactive, reliable asset.

Operational readiness that backs compliance and builds trust

The REAL Health Providers Act is shifting how provider directories are regulated, making increased accuracy, transparency, and timeliness a necessity. While the operational and compliance burdens may be significant, maintaining an always-on response to regulatory changes comes with benefits to reputation and member trust.

With an effective strategy and an investment in technology-backed data practices, teams can strengthen relationships with providers, members and staff members, through increased efficiency, user satisfaction and reduction of the administrative burden on staff members. Embracing accurate provider data management will help keep payers in compliance while building trust, showing the opportunity for alignment when operations and regulations are prioritized. 

About Lynne Rinehimer, Esq.

Lynne Rinehimer has worked in the healthcare compliance field for over 25 years. Starting her career in consulting, Lynne drafted compliance programs, served as part of the Independent Review Organization for entities under corporate integrity agreements, and led education sessions for compliance and clinical teams. Lynne manages the content in the symplr Compliance (ComplyTrack) Risk Assessment Management Solution, conducts product demonstrations, and serves as a subject matter expert and thought leader, conducting webinars throughout the year on a variety of compliance-related topics. Lynne is an attorney and a member of the Pennsylvania Bar Association.