Health Plan Provider Directories
The purpose of this article is to analyze the current state of the #providerdirectory problem, identify best practices and recommend practical approaches that practices can take to solve the problem.
Provider directories are a critical link between practices and their patients. Inaccurate information can impact access to care for patients and decrease the ability for practices to attract new patients.
The issue of directory accuracy has now become a federal issue. The Centers for Medicare & Medicaid Services (CMS) has conducted reviews of the accuracy of Medicare Advantage (MA) online provider directories and determined that close to 50% of the information was inaccurate.
As a result, #CMS issued a new rule requiring insurers to provide up-to-date physician lists for MA and Healthcare.gov policies or potentially face fines of up to $25,000 per beneficiary for any violation.
With #healthplans now at risk for fines, directory requests will require immediate action on the part of practices. In some instances, plans may withhold reimbursement or remove non-responding physicians from their directories.
Ensuring the information in health plan directories helps eliminate program benefit and billing misunderstandings that can result in payment delays, incorrect payments, and payment denials, regarding covered services, member eligibility, and billing procedures.
Provider Directories
Insurers publish directories of health care providers in their networks as a way to help consumers access care. Having accurate provider directories is crucial because even the best insurance plan is no help to consumers if they cannot find a provider who is in-network and taking appointments.
Most patients use health plan provider directories to make decisions on insurance coverage and to seek and select clinicians to provide healthcare services. The accuracy of these directories has been a longstanding problem and, despite significant efforts, minimal improvement has been observed. Patients encountering inaccuracies in health plan directories can experience delays in access to care and unexpected out-of-pocket expenses.
Health plan provider directories allow members to search and view information about in-network providers, including the practice location, phone number, specialty, hospital affiliations, whether they are accepting new patients and other details.
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When directory information is inaccurate, patients experience inconvenience (non-working phone numbers, longer time to find the right practitioner), and financial consequences (unplanned out of pocket expenses). Directory errors may also result in a patient selecting a health plan based on inaccurate information about which clinicians are in-network.
Practice Responsibilities
Practices are expected to notify health plans when clinicians leave a group or are no longer practicing at a specific location. Practices should also provide updates when locations and phone numbers change. Health plans depend on these updates to keep directory information current.
While this may appear straightforward, practices must juggle a variety of administrative burdens that interfere with their ability to comply with requests for directory updates.
To further complicate the situation, practices are often inundated with requests for provider directory information from multiple health plans through varying channels (e.g., phone calls, e-mails, health plan-specific portals) that can result in inaccurate information inadvertently being shared or updates not being shared at all.
Practices have a responsibility to provide health plans with data updates through the appropriate channel. This includes reporting changes to clinicians at the practice, addresses, phone numbers and, if applicable, ‘accepting new patients’ status in a timely manner. The No Surprises Act requires practices to have in place business processes to ensure the timely provision of provider directory information.
In an increasingly complex healthcare system with more clinicians and practices offering specialized services to diverse populations and health plans offering more benefit options, patients today have a greater need for accurate directory information to choose a doctor who is right for them. If a solid foundation of basic provider directory information is not established, then addressing rapidly evolving patient needs (e.g., virtual or specialized care) becomes more difficult.
Practical Approaches for Medical Practices
Given how accustomed consumers are to instant access to precise information, their expectations are also higher than ever before. For practices to maximize the utility of their health plan directories and to minimize the administrative burden associated with reporting provider information, practice leaders are encouraged to: