Patient Support & Advocacy

How to fix the persistent inaccurate health plan directory problem

Andis Robeznieks , Senior News Writer

While patients use a variety of search engines, doctor-rating websites and social media platforms to find physicians that suit their needs, they often turn to health-plan directories to make the final decision. Patients rely on directories to identify clinicians based on specialty, location, hours and health-plan participation. They also look to directories for information on languages spoken, special skills and experience, the availability of telehealth or LGBTQ+-friendly services.

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But too often directories contain erroneous or outdated information.  This can lead to patient frustration, delays in care, or unexpected out-of-pocket expenses. In fact, a 2020 Health Affairs study, “Incorrect Provider Directories Associated With Out-Of-Network Mental Health Care And Outpatient Surprise Bills,” showed that 53% of patients searching for such care in health-plan directories found inaccuracies. Centers for Medicare & Medicaid Services audits of Medicare Advantage plans’ online directories found similar error rates.

This problem has persisted despite efforts by policymakers and health plans to address it.

A new paper from the AMA and CAQH outlines the need for health plan-physician practice alignment, automation, and a streamlined process for producing accurate directories. It also highlights the challenges and acknowledges responsibilities of the stakeholders in the service of patients.

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Health plans rely on physician practices to notify them of changes in practice information. While this sounds straightforward, practices on average contract with more than 20 plans and can be inundated with requests for updates through phone calls, emails or health plan-specific portals. Some physician practices also report that updates they provide do not always appear in the directories.

Problems also persist because practice information changes frequently, increasing opportunities for errors. Studies find that between 20% and 30% of directory data changes annually.

Finally, the paper explains that no single party is the exclusive keeper of this information. Physician practices maintain contact information and the group roster, but health plans control information on which physicians are under contract and often, which locations are covered by the contract. Information on which physicians are accepting new patients covered by which health plan, meanwhile, is controlled by both parties.

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The AMA and CAQH outline solutions to ensure that patients have access to accurate information in health plan directories.

The paper calls for:

  • Identifying respective responsibilities and the best approaches to execute on those responsibilities.
  • Establishing data-governance standards that integrate legacy data silos.
  • Identifying greater opportunities to streamline data requests from health plans so that practices can provide data through fewer and more consistent update channels.
  • Harmonizing data systems to facilitate better quality data and facilitate development of bulk and real-time updates.
  • Agreeing on a minimum directory data set and accept shared responsibility to produce, manage and present accurate data to patients.

The paper concludes that previous efforts to improve directory accuracy have been stymied, in part, by a lack of shared understanding and responsibility between clinicians and health plans, a lack of data standards and fragmented systems to collect and transmit this information. This is exacerbated by already burdensome administrative requirements. By working together, health plans, clinicians and practices now have an opportunity to solve this problem for patients once and for all.

Learn more about what the AMA is doing to make network directories accurate and accessible.