Gone are the days of relying solely on a word-of-mouth referral for a doctor. Today, patients are accustomed to having information at their fingertips when searching for a provider or booking an appointment. Half of all patients depend on online resources, including health plan provider directories, to find an in-network physician, specialist, or facility.
Unfortunately, provider directories are often plagued with errors and incomplete data, which can result in delayed access to care and surprise medical bills. In recent years, federal and state legislators have stepped in to hold health plans accountable for the quality and accuracy of provider directory data. But updating and maintaining provider directories is yet another time-consuming administrative process. To help deliver quality and affordable care, health plans and providers need a modern solution that streamlines provider directory management.
The Provider Directory Landscape
WHAT IS A PROVIDER DIRECTORY IN HEALTHCARE?
A provider directory is a comprehensive list of healthcare providers such as physicians, hospitals, or clinics that are available to patients within a particular healthcare network or health insurance plan. Patients primarily use provider directories to find a new doctor or look up the cost of a procedure, but they are also used by insurance companies, healthcare organizations, and government agencies to manage healthcare networks, negotiate contracts with providers, and monitor the quality and availability of healthcare services.
A health plan provider directory aims to be an all-inclusive source of provider data including specialty, location, phone number, hospital affiliations, openness to accept new patients, and more. Some directories include information on health equity and accessibility issues, public transportation options, languages, and experience with specific patient populations.
POPULATING PROVIDER DIRECTORES
When a healthcare provider initially requests to participate in a health plan network, they must complete the provider credentialing and payer enrollment processes. During these initial steps, the health plan requests multiple data points from the provider—such as contact information, academic qualifications, and practice location—which helps populate their provider directory. When a provider’s information changes, perhaps due to relocation or an expired payer contract, the onus is on the provider and health plan to collaborate and update provider directories with the new data.
THE IMPORTANCE OF PROVIDER DIRECTORY ACCURACY
The U.S. healthcare system is infamous for being complex and costly. To ensure a streamlined and economical care experience, patients need to seek care services covered by a health plan. However, it’s not as simple as going to the closest clinic or using a friend’s doctor.
Patients usually need to do their own research to identify providers who meet their individual needs and preferences while allowing them to compare insurance coverage and costs. When researching various factors like specialty, location, and health plan participation, patients are increasingly relying on online sources—nearly two times more than referrals. The accuracy of provider data in online provider directories can help patients avoid expensive medical bills, and ultimately make or break the care experience.
Common Challenges with Provider Directories
Like many aspects of the healthcare industry, the current provider directory landscape is fragmented and costly. A survey of physician practices revealed that directory maintenance costs practices $2.76 billion annually. Various challenges contribute to the expense and affect the value of provider directories as a sound resource for patients, providers, and health plans.
Patient Case Example: Jane suffers from chronic arthritis. After an appointment with her long-time rheumatologist, she received an unexpected medical bill. After calling her provider’s office and health plan, Jane found out her rheumatologist transferred out-of-network after her insurer failed to reach an agreement with a newly merged healthcare group. Jane’s health plan did not update its provider directory, making it seem like her doctor was still in-network.
When issues with provider directories trickle down to patient care, it can be detrimental. Unfortunately, Jane’s situation isn’t unique—and even if health plans update their provider directories regularly, it’s nearly impossible to ensure a provider directory is 100% accurate, 100% of the time. But regulations and automation can help curb these challenges and ensure patients receive quality, affordable care.
The Impact of the No Surprises Act
In an effort to improve the timeliness and accuracy of provider directories, regulators and legislators have introduced new requirements intended to protect patients from receiving care they can’t afford. To help shine a spotlight on inaccurate provider data in directories, federal legislators passed the No Surprises Act (NSA).
What is the No Surprises Act?
The NSA is a federal law that was passed in December 2020 to protect patients from unexpected medical bills, also known as surprise billing. Surprise billing can occur when patients receive healthcare services or emergency care from a provider who is out-of-network. The NSA contains multiple provisions designed to protect patients from surprise medical bills. Here are a few of the key provisions:
- Private health plans are required to cover out-of-network claims and apply in-network cost sharing. The law applies to both job-based and non-group plans, including grandfathered plans.
- Doctors, hospitals, and other covered providers are prohibited from balance billing patients for amounts that exceed the in-network cost-sharing amounts when patients receive out-of-network care.
- Patients can request advance information about how services will be covered; and the health plan must provide written information within three business days.
- Health plans and issuers are required to establish a verification process to update provider directory information at least every 90 days. They must also notify enrollees when a provider or facility leaves the plan network.
- For any surprise, out-of-network medical bill, an independent dispute resolution (IDR) process must take place following a 30-day period when the plan and provider try to negotiate a payment amount.
The law also requires health plans to provide patients with clear and transparent information about their coverage, including information about in-network and out-of-network providers and estimated costs of care. The NSA establishes a process for resolving billing disputes between providers and health plans, and it creates an independent dispute resolution process to resolve disputes that arise from surprise bills.
The NSA applies to most group health plans, including self-insured plans, and to individual market health insurance plans. It also applies to air ambulance services and to non-emergency services provided at in-network facilities by out-of-network providers.
NSA Impact on Health Plans
Health plans have a significant responsibility due to the NSA, especially to ensure patients are protected from surprise billing. The law requires health plans to maintain accurate and up-to-date provider directories, and it imposes penalties on plans that fail to do so. Health plans must ensure that their provider directories are easily accessible and searchable, and that they provide transparent information about coverage.
NSA Impact on Providers
While health plans bear most of the burden of updating provider directories, they will not be accurate unless providers verify their information is correct and update their information when changes occur.
Simplifying Provider Data & Directory Management
The Case for a Single Directory
Due to the complexity of provider directories, there have been requests for a single source of truth. According to CMS, a study from the Council of Affordable Quality Healthcare (CAQH) estimated that collecting directory data in a single platform could save physicians $1.1 billion in annual administrative costs. In 2022, CMS officially called for a national provider directory, proposing a CMS-led directory that could potentially, “reduce directory maintenance burden on providers and payers by creating a single, centralized system, promoting real-time accuracy for patients.”
However, both provider and health plan groups denied the proposal. The American Hospital Association (AHA) explained that not every health system has the technology necessary to support a move to a single provider directory. The AHA was also skeptical that a national directory would indeed reduce providers’ administrative burden.
Modernizing Provider Directory Maintenance
Without a national directory in sight, and strong federal enforcement of the NSA, health plans are on the hook to comply with the law and keep their directories up to date. It’s critical to find a solution that eliminates data siloes, establishes a standard process, and automates directory maintenance.