The issue

Provider directories are often fraught with errors and inaccuracies, which can lead to hefty CMS fines and sanctions against health plans. As many health plans know from personal experience, provider directories can be burdensome to maintain. How can your health plan effectively maintain its provider directories?

Directories

To understand the difficulties with provider directory maintenance, one must first understand the provider directories. They’re used to help a new health plan member navigate the provider networks available to them during open enrollment, however, they can have negative backlash if the information available to plan members is inaccurate.

For example, Natalie just started a new job and received information from her employer about the health plan’s network. She searched the provider directory and found a doctor who is accepting new patients. She called the practice to schedule an annual check-up, but the receptionist said the provider was not accepting new patients. Natalie was frustrated that she couldn’t see her first choice of doctor.

Identified inaccuracies

Why does this happen more often than it should?

A CMS survey of provider directories from 2018 found that 48.74% of the provider directory locations listed had at least one inaccuracy. These included

• The provider was not at the location listed
• The phone number was incorrect
• The provider was not accepting new patients when the directory said they were.

CMS also discovered:

• Of the 5,602 providers reviewed by CMS, 50.14% (2,809) of the providers had at least one deficiency.
• Of the 10,504 locations reviewed by CMS, 48.74% (5,120) had at least one deficiency in the location.
• Of the 10,504 locations reviewed, CMS said providers should not have been listed at 33.14% (3,481) of the locations either because the provider no longer worked there or because the provider did not accept the health plan at the location.
• In 1,393 reviews, the provider should not have been listed at any of the locations in the directory.
• There were 690 incorrect or disconnected phone numbers and 364 incorrect addresses.
• Finally, there were 221 instances where the provider was no longer accepting new patients, however, the directory said they were accepting new patients.

Monitoring the directories

CMS began monitoring provider directories for accuracy in 2016. To monitor the provider directories, CMS uses an outside vendor to verify the directories accuracy. And, CMS developed an audit protocol three years ago to enhance its oversight of the validity and accuracy of provider directories, accessibility to network providers, and network standards.

A health plan risks being audited by CMS, when inaccuracies are found. Often these inaccuracies can be addressed before an audit, by having the health plan perform an internal audit of its provider directories. IQVIA’s Healthcare Center of Excellence can assist a health plan with an internal audit, includes determining what systems populate the data in provider directories and how the data is maintained.

If inaccuracies are found during a CMS audit, the agency can levy civil monetary penalties or enrollment sanctions against the health plan. Fines for non-compliance can cost a health plan as much as $25,000 per day, per beneficiary for not maintaining what CMS says is, “regular, ongoing communications/contact (quarterly) with providers (Medicare Advantage Notice).”

CMS can also levy penalties of up to $100 per day, per individual affected by a Qualified Health Plan (QHP) who does not update their provider directories at least once a month. Machine readable directory requirements align with QHP obligations, which say health plans have 30 days to update electronic provider directories after the provider information has been received.

States can also fine health plans for inaccuracies in their provider directories. According to a 2016 AHIP/Availity white paper, The Provider Directory Dilemma, state regulations are often more stringent than federal regulations (see Page 3 of the white paper for a state-by-state comparison). The regulations can also affect government-funded and commercial plans. Not all states regulate provider directories.

Provider challenges

Inaccuracies in provider directories can often be attributed to providers struggling with how to respond to a health plan’s request for data, because:

• The provider receives multiple requests from several different health plans on an ongoing basis.
• The data submission requirements are different for each health plan and can become a burden to the provider’s staff.
• There is no standardization for health plans to ask questions of the provider.

Health plan challenges

Health plans face their own set of challenges, including:

• Getting providers to comply with their requests and respond.
• Providers are angry and frustrated because of the number of health plan requests they receive.
• An inability to validate the provider’s location.
• Lack of “source of truth” for provider data.

The health plan also struggles with workflow integration issues, including being able to synchronize all systems with the data, and having the necessary tools, technology, and staff to complete the necessary integration work.

Areas for improvement

CMS’ study found that when a health plan obtains information directly from providers, the accuracy of the data improves. Real time updates to online provider directories must occur within 30 days. This occurs when the health plan receives notification of changes in a provider’s status, participation in a network, and/or demographic data, or when health plan makes contract changes to its network of providers.

In addition, this ensures the accuracy of online provider data and that included in a printed directory. Health plans can ensure provider directories are accurate by addressing customer inquiries and complaints, including promptly addressing members who are denied access to providers who said they were not accepting new patients, and following up to make sure the corrections were made in the directory.

Data quality

IQVIA’s Healthcare Technology practice takes a practical approach to data quality in health plan provider directories. We take several different approaches to assisting clients with maintaining data accuracy in their provider directories.

For example, we’ll look at a provider’s billing address and service address compared to external sources and update the information, accordingly, based on what’s found from the external sources.

Let us help you effectively maintain your provider directories.