Patients normally research networks and providers before they enroll in a new healthcare plan or seek medical care from a new specialist. However, a 2023 study found over 80% of provider directory listings across five payers demonstrated inconsistencies or inaccuracies—a total representing over 40% of physicians practicing in the US.
These issues can prevent patients from receiving timely care. This, in turn, can affect their quality of life or be life-threatening in some cases.
What are patients supposed to do if the directory information itself is inaccurate or erroneous? Below, we’ll explore why data accuracy is crucial, common issues with provider directories, and how providers who make efforts to ensure the accuracy of their directory information promote better patient access.
What Are Provider Directories and Who Uses Them?
Healthcare plan insurers (i.e., payers) must maintain a list that informs patients about available, in-network healthcare providers with whom they can schedule appointments; this list is referred to as a ‘provider directory.’ Payers and providers collaborate to maintain these directories for patients.
Patients most often use provider directories to schedule appointments or shop for healthcare plans. Directories prove especially important when patients select a plan, as the information in the directory allows them to ensure that existing providers remain covered within the new network (if desired). The directory will also give them information for accessing any other providers they anticipate needing (for instance, if they need to see a specialist).
Why Provider Accuracy Is Crucial
When patients reference a provider directory, they do so with the assumption that the information presented is accurate and current. However, that isn’t always the case. In fact, network adequacy and provider directory accuracy have remained a widely acknowledged challenge across the US healthcare industry for more than ten years.
As Jack Resneck, Jr., MD—then-president of the American Medical Association (AMA)—stated in 2023 before the US Senate Committee on Finance, “when directory information is incorrect, the results can be complicated, irritating, expensive, and potentially devastating, especially to patients.” Dr. Resneck also went on to say that inaccurate data often leads to financial consequences for patients (e.g., they’re forced to seek out-of-network care) or delayed treatment.
According to the Centers for Medicare and Medicaid Services (CMS) and the No Surprises Rules, provider directories must include specific information regarding individual healthcare providers and for each medical group, clinic, or facility that contractually participates in the payer’s given network.
For individual healthcare providers, the directory must accurately include their:
- Names
- Addresses
- Medical Specialty
- Phone numbers
- Digital contact information (e.g., website, email address)
For medical groups, clinics, and other healthcare facilities contracted with a payer, the provider search directory information must be the same as above, with the exception of medical specialties.
Although providers and payers must work together and exchange information to keep directories accurate, payers bear most of the responsibility for this provider data management in healthcare. Accurate provider data is the foundation of network transparency and patient trust. Explore our healthcare provider data solutions to ensure your directories meet regulatory standards while enhancing accessibility and accuracy.
Common Issues With Provider Directories
Patients who struggle with provider CMS directory accuracy might experience some (or all) of the following issues:
Outdated Contact Information
On the same day in 2023 that Dr. Resneck spoke before the Senate Committee, Sen. Ron Wyden, D-Ore (then-chair of the committee), shared a provider directory accuracy study with similar findings. The report documented attempts to contact 120 providers belonging to 12 different networks. Surprisingly, only 80 of the listed numbers worked or returned calls, and roughly 100 of the providers didn’t have any appointments available.
This shows how provider directories often present patients with outdated or inaccurate contact information (e.g., phone number, address) and operating hours. This can happen if providers move locations or terminate their contract with a payer, and the payer doesn’t update the directory as they’re supposed to.
Incorrect Provider Status
Provider information can also be incorrect due to outdated statuses, such as ‘accepting new patients,’ incorrect network membership, or providers being categorized under the wrong specialties.
Incorrect provider information can also be caused by data entry errors that should have been caught and fixed during information verification processes.
Duplicate Providers
Provider directories sometimes contain redundancies, where medical professionals or facilities are listed multiple times. This can happen for various reasons. For example, a simple reason might be that the provider can practice or treat patients at numerous facilities as needed, but normally works from one.
Providers and payers may also purposefully duplicate information to try and make networks appear larger and more robust—for instance, they may have one provider at one location listed repeatedly with slight name variations. When discovered, red flags like these are often noted by the National Practitioner Data Bank (NPDB)—a federal database that helps ensure provider data accuracy and regulatory compliance.
Poor Internal Workflows
Directory information can become inaccurate if providers and payers don’t communicate effectively, or if their internal processes cause delays, oversights, or errors. For instance, perhaps a provider notices their information listed incorrectly in the directory and calls the payer, but the task is forgotten, with little to no accountability for following up.
However, prior authorizations (PA) remain one of the most common culprits impacting internal workflows. According to the 2024 AMA prior authorization physician survey, physicians reported that their practices average 39 PAs per physician, per week.
Continually dealing with so much processing and paperwork for PAs can lead to directory errors. That’s because some providers may not have the time to regularly update their directory information and continuously ensure its accuracy.
Regulatory Requirements and Penalties
Aside from patients, providers, and payers, regulatory authorities may also frequently access provider directories for investigative purposes. For this reason, provider directory accuracy regulations require payers to maintain accurate directories and ensure health plans comply with federal or state standards for healthcare access.
For the federal standard on a directory’s accuracy, the No Surprises Rules initially identified four circumstances that initiate an update:
- When providers or facilities contractually join a payer’s network
- When providers or facilities terminate their contract and leave a payer’s network
- When directory information changes (e.g., a provider’s name changes, a facility moves addresses)
- Any time a payer, provider, facility, or the Secretary of Health and Human Services (HHS) makes a request.
Per the 2023 State Efforts to Coordinate Provider Directory Accuracy: Final Report, payers must also:
- Update directory information within two days after a provider notifies the payer.
- Respond within one day to patients requesting whether a given provider is in-network.
- Verify provider directory information every 90 days.
Currently, CMS reports that numerous enforcement actions have been taken in response to issues with hospital price transparency. However, the agency does not seem to have assessed penalties yet for other inaccurate directory information.
Best Practices for Maintaining Provider Directory Accuracy
Providers and payers looking to maintain their provider data quality and accuracy should implement robust internal controls. This starts with provider self-attestation, where providers check to make sure directory listings are accurate. However, this method still depends on payers continuously updating the information if there’s no portal or access for providers to enter it themselves.
Additional best practices for accuracy include:
- Using data validation tools to ensure uniform data formats
- Integrating systems with credentialing databases
By leveraging healthcare provider data management platforms, healthcare organizations can unify credentialing, directory updates, and data governance under one automated workflow.
Better Data, Better Access with Verisys
Patients deserve access to the best, most affordable care possible. But provider directories that offer inaccurate information continually put barriers and obstacles in their way.
Without a trustworthy directory, it’s a game of chance whether a patient can contact a provider, set up an appointment, and even drive to the right address. Provider accuracy reverses that outcome, as patients better understand their network and covered providers, and they can easily learn about appointment availability as long as the contact information is correct.
Still, after updating directory listings, providers and payers will need to encourage ongoing monitoring, perform validation, and hold each other accountable. One of the best methods to do so is by partnering with Verisys. We’ll ensure easy access to healthcare provider data sets that help confirm directory listings, supporting both accuracy and access for patients.
Talk to an expert today to learn more.
Sources:
JAMA. Consistency of Physician Data Across Health Insurer Directories. https://jamanetwork.com/journals/jama/fullarticle/2802329
Jack Resneck, Jr., MD President American Medical Association. Re: Barriers to Mental Health Care: Improving Provider Directory Accuracy to Reduce the Prevalence of Ghost Networks. https://www.finance.senate.gov/imo/media/doc/Jack%20Resneck%20MD%20Statement%20to%20Finance%20Cmt%20on%20Behalf%20of%20AMA%20Re%20Provider%20Directories%202023-5-3.pdf
CMS. The No Surprises Act’s Continuity of Care, Provider Directory, and Public Disclosure Requirements. https://www.cms.gov/files/document/a274577-1b-training-2nsa-disclosure-continuity-care-directoriesfinal-508.pdf
AMA. Evidence on inaccurate directories piles up. It’s time to act. https://www.ama-assn.org/health-care-advocacy/access-care/evidence-inaccurate-directories-piles-it-s-time-act
AMA. 2024 prior authorization survey physician. https://www.ama-assn.org/system/files/prior-authorization-survey.pdf
CMS. Enforcement Actions. https://www.cms.gov/priorities/key-initiatives/hospital-price-transparency/enforcement-actions
