Inaccurate provider directories: Time to change an unhealthy inconvenience to consumers

Health plans have long supplied their members with provider directories to assist in finding in-network physicians who are accepting new patients.

But what should be a helpful aid often isn't, due to outdated or just plain wrong data. Not only is this frustrating for patients trying to find an available provider, it can cost them more than they anticipated if they end up incurring out-of-network fees for a physician they thought was in-network.

As such, angry consumers have raised the issue to the point they've ignited a full-fledged government response. New regulations went into effect in 2016 that allow 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 Individual states are also holding health plans accountable with their own rules for provider directories. In November, two large health plans were fined a total of half a million dollars for errors in their state directories.1 Meanwhile, consumer watchdogs are increasingly targeting health plans with lawsuits to recover compensatory and punitive damages caused by incorrect provider directories.2

Health plans are realizing the financial risks of not addressing provider data accuracy are becoming too big to ignore. To that end, these organizations have an opportunity to recalibrate how provider data is collected, stored and updated. The following includes top recommendations in regards to provider data:

Conduct provider system audits
With legacy systems and entrenched processes, it is difficult to understand the full scope of resources involved in gathering and maintaining provider data. Conducting an audit of both can provide health plans with insight into where there are redundancies and deliver a roadmap for what can be consolidated.

Reconsider the number of required data elements
Is it more important to get all the data, or is it more important to get clean data? It's a question many health plans should ask if they are capturing a large number of data elements. If they can address state and federal mandates using a core set of data elements, they can streamline the process for providers.

Improve provider communication
Health plans can save time and improve data quality by identifying individuals within a provider office or facility who manage a particular area or program, and then contacting that person with questions. Too often, health plans simply call into a provider office to address a specific issue, only to end up speaking with someone who can't answer their questions. This is clearly inefficient for both parties.

Incentivize providers
Health plans currently bear full responsibility for the accuracy of provider directories. Health plans may want to consider ways to incentivize providers for providing timely updates. It's also important for health plans to educate providers on how bad data affects the processing of their claims.

Leverage an Intelligent, Multi-Payer Technology Platform
Health plans have built a variety of online portals and other online tools in an effort to improve communications with providers. In doing so, however, they've lost sight of the fact that providers work with many other health plans. For providers and their staff, having to use multiple portals—each with its own design and navigation—can make the process of communicating with the health plans more complicated.

Multi-payer platforms provide a far more user-friendly option, giving providers a single point of entry and streamlined navigation. Best of all, they need only update demographic information one time to have the data sent to all participating health plans. Providers don't have to manually complete forms, and they don't have to manipulate their data to accommodate the health plan's preferred data structure.

Processes that are part of the provider workflow
Health plans can greatly improve their chances of getting up-to-date data from providers by making it part of the existing workflow. Here's an example of how it works: A staff person in a provider office is submitting a claim to a health plan or checking benefits when the system identifies a potential address mismatch. The system flags the record. When the staff member with responsibility for updating records logs into the system, he or she receives a message that prompts them to correct that record. This change goes all the way upstream to wherever provider information is captured and displayed—such as a provider directory.

Health plans should take an inaccurate provider directory as a clear sign that it's time to do something about the accuracy of their provider data. Start with a thorough review of existing methods, then update and enable these processes with a multi-plan platform. Soon provider data will be more accurate--and healthcare consumers more satisfied.

Mark Martin is Director, Payer and Vendor Portfolio, at Availity.

1 Rosin, Tamara. "Health insurers now face steep fines for outdated physician directories," Becker's Hospital Review, December 29, 2015 (retrieved from
2 Ibid.

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