The Centers for Medicare & Medicaid Services (CMS) released a report in January on the accuracy of provider directories, the online lists provided by insurers and used by health plan enrollees to find in-network doctors or select a plan in which their preferred caregiver participates.
Of the 108 provider locations examined, CMS found that on average, 45% of Medicare Advantage physician directories contained inaccuracies, including incorrect office locations and phone numbers, as well as erroneous information on whether a given provider was accepting new patients.
A month after the CMS report was published, the California Department of Managed Care (CDMC) announced that it uncovered its own provider directory problem. When reviewing insurers’ attestations to the timely access of care, CDMC found that 90% of the submitted reports contained “one or more significant data inaccuracies.”
For health plan members, poor directories not only create barriers to care they also put consumers at risk for unexpected medical costs if they visit an out-of-network physician. For providers, it’s yet another time-consuming data request from the dozen or more health plans with whom they contract.
As for insurers, the data compliance “stick”—in the form of stiff financial penalties and lawsuits—is waved exclusively at them.
In 2015, for example, two California insurers were subject to fines and consumer lawsuits due to overstating their physician networks during the 2014 ACA rollout. And in 2016, new regulations went into effect that allows CMS to fine health plans up to $25,000 per Medicare beneficiary for errors in Medicare Advantage plan directories and up to $100 per beneficiary for mistakes in plans sold on HealthCare.gov.
At the state level, penalties for inaccurate directories can be even stricter than federal guidelines, and because compliance mandates vary by state, the administrative burden for health plans with multi-state networks can be daunting.
A tough nut to crack
At an elemental level how hard can it possibly be to keep provider directories updated?
The question assumes that provider data is largely stagnant and should be relatively easy to maintain. In fact, the opposite is true.
Many health plans still rely on legacy systems where provider data is stored in multiple, disconnected databases. As business requirements have evolved, organizations have implemented incremental stop-gap measures to address data limitations, but these don’t address the core challenge: the lack of a single source of truth.
Therefore, to create directories, provider data must be cross-referenced against multiple systems, which means it’s more likely to contain redundancies and incomplete or incorrect data.
For example, health plans often update provider data annually as part of the contract and credentialing process, using this information to populate provider directories. For providers, documenting this information takes time as a detailed record can track up to 380 distinct line items, including service locations, billing locations, payment locations, specialties, certifications, affiliations, office hours, and languages spoken.
From a standards perspective, it’s not unusual that the provider’s information doesn’t conform to the data structure required by the health plan. Take, for example, whether a provider is accepting new patients. Most health plans capture this data as a binary—yes or no—field, but the reality can be more nuanced. A provider specializing in a certain branch of medicine may be willing to accept patients that meet certain criteria, but not the general population. Or the specialist may be able to accommodate new patients at one service location, but not at another.