Provider Directories are a Mess – Who Should Fix Them, and How?

Last October, I appeared on Monitor Mondays to examine a Centers for Medicare & Medicaid Services (CMS) proposal to develop a single, national provider directory, maintained by CMS. That proposal generated over 500 industry comments, and hasn’t moved at all in the regulatory process. Its future seems murky at best.

Meanwhile, CMS has stated that there are thousands of directories in healthcare today, on which billions of dollars are spent annually trying to maintain accuracy. Even with those expenditures, accuracy rates sit at 50 percent and lower, in many cases.

Now, let’s fast-forward to a couple of weeks ago, after months of what I’ll call “loving nudges” by my wife, when I decided to make check-up appointments with a primary care physician (PCP), an optometrist, and a dentist. Since I recently moved, I logged on to my health plan’s web page (sponsored by my wife’s employer) and found their provider directory to locate these various providers.

The experience was quite seamless, until I started digging into the providers listed, that is. The state of information in the directory was nothing short of tragic. Various missing data fields, incorrect phone numbers and addresses, and active providers listed as taking new patients who had either retired or died were ubiquitous.

This tracks with a study published just last month by the University of Colorado Medical School, which found persistent problems with provider directories, including regularly inconsistent information on doctors’ addresses and specialties, as well as inconsistencies between the directories of five major health plans.

Clearly, the issues CMS was trying to solve via their proposed national provider directory remain. Many of these directories are a total mess, and some have even called them a disaster for patients.

So, how can we fix these difficulties, and who should bare the brunt of maintaining provider directory accuracy? Should it be the health plans, the providers, or both? What data fields are most essential? Which electronic interface is best? And should compliance be enforced? If so, how? Via financial penalties, probationary periods, withheld reimbursement? I ask this last question specifically because, as of today, no real penalties exist for incorrect or outdated provider directories.

On top of all that, last week I attended a national conference of payors, providers, healthcare administrators, etc., where no consensus was found on any of these questions in terms of genuine, real-world answers.

All of these things made me feel like a brief primer was in order.

Both Congress and federal agencies have acted to improve the accuracy of provider directories. Their efforts and implemented requirements have been expansive. But if we view these things on a program-by-program or plan-by-plan basis, we’re left with even more incongruity and the same old mess.   

Here are just a few discrepancies by plan type:

• Medicare Advantage (MA) has its own standardized provider directory form that’s disclosed annually to MA plan enrollees, coupled with an outline of requirements on timing of provider directory communications. MA plans must update directory information anytime they become aware of changes, but cannot take over 30 days to do so. Most recently, a 2023 rule now requires that MA directories include providers’ cultural and linguistic capabilities.

• Medicaid agencies must publish and update at least annually a directory of certain physicians who participate in a state’s fee-for-service (FFS) program. Other providers may be included at the state’s option, as may certain added information about the providers.

• Patient Protection and Affordable Care Act (PPACA) Exchange plan directories must be formatted to allow third-party creation of resources that aggregate information on different plans.

• Per the Consolidated Appropriations Act (CAA), group and individual plan directories must establish a process to verify their directory data at least every 90 days, while the No Surprises Act (NSA), which stems from the CAA, requires that consumers who use providers they believe are in-network based on inaccurate data in their insurer’s provider directory will pay no more than their in-network cost-sharing amount, regardless.

Finally, CMS has made multiple attempts at provider directory oversight. For example, they audited PPACA plans from 2017-2021, and they implemented a monitoring program of MA plan offerings in 2016, with a follow-up in 2020. In each instance, countless inaccuracies and violations were found, but no enforcement mechanisms were triggered, and no penalties were levied.

A co-author of the University of Colorado study I mentioned earlier stated in an interview that neither providers nor insurers are ultimately to blame for the provider directory mess we have on our hands, as they both face challenges in ensuring data accuracy.

He described it as a problem technology could solve, possibly through some sort of standardization. But that just brings us full circle, back to CMS’s proposal of a national, single directory, which, as we know, has been met with much skepticism and a gloomy outlook.

But if the provider and health plan communities want to avoid something of a forced government intervention on this issue, and support consumer access to care, they must come together in short order to find commonalities and shared aims in this area, then put them into practice.