Inaccurate Health Plan Provider Directories Cause Too Many Problems

The failure of the AHCA to go up for a vote showed us that health care reform will continue to be uncertain; there will be much more deliberation about its future and how to stabilize the insurance markets. Regardless of the future of the Affordable Care Act, provider directories will still need to be accurate for consumers to find the care they need when they need it. Healthcare, as an industry, is moving towards consumerization whether regulators, health plans, hospitals, or health systems like it or not. It is the reality we live in.

People need and expect healthcare on-demand. We are starting to see how health insurance companies, health groups, and health systems move towards the consumerization of healthcare. This will inevitably demand that all provider directories—including those in health plan & health system directories—provide information that is accurate and consistently refreshed.

 

What is wrong with provider directories?

Finding the right doctor shouldn’t be difficult. Health plan provider directories, often available in a searchable format online, are an important tool in helping individuals and families find the care they need. Yet, despite federal and state laws designed to ensure the accuracy of these listings, key information often is missing or out of date. Individuals who rely on the information in provider directories may be denied care or end up with unexpected medical bills.

America’s health plans understand the importance of providing accurate provider data, but maintaining this information accurately is not easy. Providers may not give health plans updated information in a timely fashion, and health plans may have a difficult time keeping up with frequent changes. This not only causes problems for individual patients, but also may overstate the adequacy of provider networks.

 

What are federal and state regulators doing to help ease the problem on consumers?

Adding to the difficulty in maintaining accurate provider directories, the Centers for Medicare & Medicaid Services (CMS), the National Association of Insurance Commissioners, and most states have established regulations governing provider directories.

Three states that have passed separate bills focused on provider directories—California, Maryland, and Georgia—have some of the strictest requirements in the country. They mandate the inclusion of comprehensive information and require multiple updates a year. Other states, such as Florida and Pennsylvania, include strict provider directory requirements as part of broader laws aimed at protecting healthcare consumers. Still, other states have yet to offer specific guidance.

Federal regulations mandate accurate provider directories for Medicare Advantage plans or policies sold in the federally run health exchange. In 2016, CMS surveyed 54 Medicare Advantage plans, representing approximately a third of all Medicare Advantage Organizations (MAOs), with 5,832 providers. It reported in early 2017 that nearly half (45.1%) of the Medicare Advantage provider directories it reviewed were inaccurate. Common errors included providers not at the location listed, incorrect phone numbers, and providers not accepting new patients when the directory indicated they were.

Because MAO members rely on provider directories to locate an in-network provider, these inaccuracies pose a significant access to care barrier,” CMS said. In response, the agency issued 31 notices of noncompliance and 21 warning letters. Penalties for the 21 insurers with high rates of errors range from fines to sanctions, which could include suspending enrollment.

 

How can we, as an industry, fix provider directories?

To fix provider directories, the healthcare industry must rebuild and redesign their technological processes to update directories. We are 10 or 20 years behind what our counterparts in the banking industry did; they modernized fast and have benefited because of it. For example, we need to leverage real-time data platforms and metadata to improve healthcare delivery.

At BetterDoctor, we help health plans to clean and validate their provider directory data and work with them to figure out how to build sustainable systems that will allow them to refresh data via application program interfaces (APIs). We see, day in and day out, how challenging it can be to administer and update a provider directory with smooth cooperation with all stakeholders involved (i.e. provider, health systems, etc).

Additionally, health plans, health systems, and providers have to collaborate to make provider directories more accurate and not have to carry the administrative burden of doing it all on their own. To test this, America’s Insurance Plans (AHIP) developed a pilot to figure out the most cost-effective and productive ways to update provider directories.

The pilot was part of an industry-wide effort to improve consumers’ access to care and provide them with the information needed to make informed healthcare decisions. BetterDoctor proactively approached providers and their staff with phone calls, faxes, emails, and alerts within existing online portals asking them to update important data—such as address, phone number, specialty, and type of insurance accepted. Health plans were then able to process information about new locations and contact information to update their provider directories.

 

Going forward

In order to improve the overall experience of finding a doctor, accurate data is a must-have. There is a lot of work to do. Delivering products in a highly regulated industry is challenging, especially when inaccurate data derails the quality of the service the healthcare industry provides. Building real-time data platforms with continuously refreshed metadata can strengthen the credibility of data for everyone. Regulatory compliance with new data-quality laws will naturally follow when these transparent systems are created to share data.

More importantly, people will eventually enjoy a better user experience when they interface with accurate provider data that lets them find the healthcare that they need.

Ari Tulla

Ari is the CEO and Co-Founder of BetterDoctor. His personal struggles with finding the right doctor for family health issues led him to start the company. Prior to BetterDoctor, Ari led Nokia’s game and application studios where he was responsible for the creation of thousands of mobile apps with over 100M downloads. Ari has over a decade of experience on creating new delightful consumer products and experiences.

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