Provider Directory Accuracy – Health Plans’ Continuing Challenge

Posted by Joe Stefansky on May 16, 2023 in CMS, Industry News,

In 2018, CMS released a report that set forth the results of their review of Medicare Advantage online provider directories. The review examined the accuracy of 108 providers and their listed locations selected from the online directories of 52 Medicare Advantage Organizations (MAOs), approximately one-third of MAOs, for a total of 5,602 providers reviewed at 10,504 locations. The results were not encouraging – 48.74% of the provider directory locations had at least one inaccuracy, which included:

  • The provider was not at the location listed;
  • The phone number was incorrect; or
  • The provider was not accepting new patients when the directory indicated they were.

In 2020, the federal No Surprises Act was passed and included provisions meant to force health insurers to clean up their provider directories. This Act went into effect January 1, 2022. The No Surprises Act provider directory requirements apply to health care providers and health care facilities. The statute doesn’t exempt any categories of providers or facilities from this requirement. The No Surprises Act protects individuals who inadvertently seek care from an out- of-network provider or health care facility after relying on inaccurate provider directory information.

Requirements under the No Surprises Act don’t apply to beneficiaries or enrollees in Medicare, Medicaid, Indian Health Services, Veterans Affairs Health Care, or TRICARE, but do apply broadly to commercial group and individual plan coverages. However, Medicaid and Medicare plan contracts across the country include requirements regarding directory accuracy.

 At a minimum, providers and health care facilities subject to the No Surprises Act must submit provider directory information to a plan or issuer:

  • When the provider or health care facility begins a network agreement with a plan or issuer with respect to certain coverage;
  • When the provider or health care facility terminates a network agreement with a plan or issuer with respect to certain coverage;
  • When there are material changes to the content of provider directory information of the provider or health care facility;
  • At any other time (including upon the request of plan or issuer) determined appropriate by the provider, health care facility, or the Secretary of Health and Human Services (HHS).

Providers must submit to a health plan provider directory the following: names, addresses, specialty, telephone numbers, and digital contact information of individual health care providers; and names, addresses, telephone numbers, and digital contact information of each medical group, clinic, or healthcare facility contracted to participate in any of the networks of the group health plan or health insurance coverage involved.

The No Surprises Act requires health plans to verify all provider directory data every 90 days, process updates within two business days of receiving updated information and remove providers from the process updates within two business days of receiving updated information and remove providers from the directory if their information has not been verified during a period specified by the health plan.  Print directories must include the date of the last update.

In March 2023,  JAMA published a study conducted in September of 2022 which analyzed the consistency of provider data across publicly available directories of five large national health insurers. Over 634,000 unique providers were identified of which almost 450,000 were listed in more than one insurer’s directory. The findings reflected the accuracy of both provider address as well as provider specialty information. Overall, where a provider practiced in one location, accuracy rate was almost 59%. However, for providers with multiple locations, the results reflected an average of 19.4%. These findings would indicate that the impact of the No Surprises Act provisions related to provider directory accuracy were not yet evident at the time of the 2022 study.

Provider Directory Challenges Facing Health Insurers

The No Surprises Act provisions related to directories have certainly clarified expectations of the federal government for both providers and insurers to significantly improve the information available to their patients and enrollees.  However, for many health plans which contract with multiple medical groups, hospitals and facilities, their poor accuracy rates do not necessarily reflect the efforts made to maintain the latest information for their enrollees. In many cases, providers have not historically viewed updating insurers regarding provider location is a priority when compared to patient care or billing. While a large national insurer may have some leverage to require that updated provider data is sent regularly and in a format that can be used, smaller plans are often not in a position to make such demands because they have limited alternative options for patient care. When a hospital system sends a data dump of all current providers and locations, without noting changes from the prior submission, a smaller insurer may not have the resources to quickly identify what changes require updates. In addition, the frequency of updates can be tied to a larger plan’s timetable, and in the format dictated by that plan. There can be internal plan structures that also drive challenges with the timeliness of updates, when one department is responsible for obtaining the information while another updates the directories. The No Surprises Act gives insurers new leverage to demand that providers submit the required data in a timely and  consistent manner. However, the Act also increases insurer exposure for failure to comply with the new requirements, and may spur those with internal structural challenges to deploy the resources necessary to improve performance.

About Joe Stefansky

About Joe Stefansky

Joe Stefansky has a keen sense of business opportunities in complex problems, using technology to transform difficulty into efficiency. The CEO and founder of Streamline Verify specializes in solving compliance, legal and administrative issues through intuitively designed software that reduces costs and saves time.

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