The AMA is supporting a movement in Congress to fix inaccurate provider directories in Medicare Advantage, a problem that’s burdening physicians and negatively affecting patient outcomes.
Studies have found inaccuracies with physician locations, network status, availability to accept new enrollees, and physician specialties. Patients may look at a directory and assume their doctor is in network—and they’re not. Or a patient may not be able to find a specific physician because their information is outdated.
Senate Finance Committee Chair Ron Wyden (D-Ore.), and Ranking Member Mike Crapo (R-Idaho) are working to stop these inaccuracies. The Better Mental Health Care, Lower-Cost Drugs, and Extenders Act of 2023, legislation approved by the committee requires that Medicare Advantage plans have accurate and updated provider directories, through stepped up verification, transparency and reporting processes. The measure also protects beneficiaries from financial harms of directory inaccuracies.
AMA Executive Vice President and CEO James L. Madara, MD, backed the provider directory in a letter (PDF) to Sens. Wyden and Crapo.
“Inaccurate directory information can have severe financial consequences for patients, placing the burden on them to invest significant time in finding an in-network provider or facing the expense of out-of-network care,” wrote Dr. Madara. “Continuing to allow inaccuracies makes it easier for plans to fail to build networks that are adequate and responsive to enrollees’ needs.”
Some of the bill’s provisions were enacted into law as part of the federal government-funding deal struck in March.
Protecting patients and physicians
The legislation ultimately makes it the plan’s responsibility to update provider directories and to hold Medicare Advantage plan beneficiaries harmless if they see an out-of-network physician or other health professional who’s inaccurately listed in an outdated directory as being in-network.
Plans must ensure that the beneficiary is responsible for no more than the in-network cost sharing amount for services provided in the 2026 plan year by a provider who is not in-network but included in the Medicare Advantage plan provider directory. This includes beneficiaries covered by HMO plans or plans with no out-of-network benefit.
Separately, the AMA has partnered with the data-solutions firm CAQH on a white paper that calls for a series of actions to improve patient access to accurate information in health-plan directories. These include harmonizing data systems to facilitate better quality data and facilitate development of bulk and real-time updates, and identifying opportunities to streamline data requests from health plans so that practices can provide data through fewer and more consistent update channels.
