Improving Value

Provider Directory Accuracy

A provider directory is list of in-network healthcare providers, generally provided by an insurer, to help enrollees find in-network care. Consumers use provider directories at the point of health plan shopping to ensure that doctors they already have are in-network and as a tool when they need to identify a new healthcare provider for care. Consumers, regulators and policymakers use provider directories to assess provider network adequacy

Inaccurate or out-of-date provider directories curtail a consumer’s ability to find in-network providers, potentially increasing their costs significantly.1 If consumers do not have an accurate list of in-network providers, they may incur out-of-network costs in the form of surprise medical bills, having seen a provider they believed was in-network. Indeed, a 2018 survey found that over half of physicians reported that their patients faced coverage issues due to provider directory accuracy issues.2

Myriad studies have shown that provider directories suffer from high rates of inaccuracies:

  • A 2020 national survey of privately insured patients who received specialty mental health treatment revealed that of the 44 percent of patients who used a mental health provider directory, 53 percent of them encountered directory inaccuracies.3 This survey also reveals that those who encountered inaccuracies were twice as likely to be treated by an out-of-network provider and four times more likely to receive a surprise outpatient out-of-network bill. 
  • Federal audits of Medicare Advantage plans’ provider directories in 2018 revealed that nearly 50 percent of provider directory locations contained at least one mistake, including wrong location, phone number or the provider was not accepting new patients as the list indicated.4
  • A December 2014 HHS Office of Inspector General report on Medicaid Managed Care found that slightly more than half of providers could not offer appointments to enrollees. About 35 percent could not be found at the location listed by the plan, and another 8 percent were at the location but said that they were not participating in the plan. An additional 8 percent were not accepting new patients.5
  • Researchers at UCSF tried contacting all 4,754 dermatologists listed in the three largest Medicare Advantage plans in 12 metro areas. Nearly half the listings were duplicates and only about half the remaining were at the listed address, accepted the plan and were offering appointments.6
  • A November 2015 survey from the Maryland Women's Coalition for Healthcare Reform7 found that of 1,530 OB/GYN providers listed in the state’s on-line directory, just 22% met three criteria: providing well-woman visits; accepting new patients; and available for an appointment in four weeks or less. In addition, 423 had inaccurate or incomplete listings, 92 were part of a closed panel, 24 were not OB/GYNs or sub specialists, and 85 were not accepting new patients. The result—only 33% met the criteria of accepting new patients and providing a well-women visit.8 

The federal government has minimum standards for private health plans sold on the ACA Marketplaces, requiring them to update their provider directories monthly and collect up-to-date information from providers quarterly.9 Several states have rules requiring more frequent updates to online provider directories and/or apply those rules to more types of health plans. While update requirements are helpful, they may not be enough to protect consumers if health plans don’t also take steps to ensure the accuracy of the information, such as:

  • Conduct regular audits of provider directories, with discretionary edits based on findings;
  • Contact inactive providers;
  • Guarantee to honor provider director information. 

Certain states have already passed stronger measures, including California, Texas, New Jersey, and Washington, D.C.10

The National Association of Insurance Commissioners has a model law that includes a mechanism for the public to report directory inaccuracies to health plans and a requirement that insurers periodically audit their directories.11 Additionally, this model law includes continuity of care protections for patients who are in the middle of an active course of treatment if their providers leave or are removed from their health plan’s network. Though the consumer-friendly features of this model law make it a useful tool improve the accuracy of provider directories and protect consumers, most states have not adopted this model language.

 

Notes

1. Families USA, "10 Steps to Improve Provider Directory Accuracy." 

2. O'Rielly, Kevin B., "Directory-Related Mishaps Affect Patients Monthly, Say Doctors," American Medical Association (April 30, 2018).

3. Busch, Susan H. and Kelly A. Kyanko, "Incorrect Provider Directories Associated with Out-of-Network Mental Health Care and Outpatient Surprise Bills," Health Affairs, Vol. 39, No. 6 (June 2020). 

4. Luthi, Susannah, "Medicare Advantage Provider Directories Still Riddles with Errors,Modern Healthcare(December 4, 2018).  

5. Department of Health and Human Services, "Access to Care: Provider Availability in Medicaid Managed Care," (December 2014). 

6. Resneck, Jack S. Jr., et al., "The Academy of Dermatology Network Physician Directories Posted by Medicare Advantage Health Plans in an Era of Narrow Networks," JAMA Dermatology, Vol. 150, N. 12 (December 2014). 

7. Maryland Women's Coalition for Healthcare Reform, Website Home Page.  

8. Maryland Women's Coalition for Healthcare Reform, "Network Adequacy in Maryland: A Report on Provider Directories and Women's Access to Health Care Services," (November 2015). 

9. National Association of Insurance Commissioners, "Network Adequacy," (April 18, 2019). 

10. Families USA, "Improving the Accuracy of Health Insurance Plans' Provider Directories," (October 2015). 

11. National Association of Insurance Commissioners, "Health Benefit Plan Network Access and Adequacy Model Act," (2015). 

 

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