Improving the Accuracy of Health Plan Provider Directories

The Issue

The information in health plans’ provider directories is often inaccurate. A 2018 report from the Centers for Medicare and Medicaid Services (CMS) found that 52 percent of physician listings in Medicare Advantage (MA) provider directories contained at least one inaccuracy. Typical errors include wrong phone numbers; incorrectly listing in-network providers as accepting new patients when they are not; and omitting in-network providers from directories.

Provider directories are commonly posted online as PDFs or other “flat file” formats. But most Affordable Care Act (ACA) marketplaces (both state and federally managed) require that they be available in machine-readable formats, which can be easily downloaded and read by computers to identify information that is likely incorrect. A Commonwealth Fund–supported study compared the accuracy of four sources of provider information from five U.S. counties: 1) machine-readable directories from exchange plans; 2) MA plan directories with traditional flat-file directories; 3) online information from Google Places, which is self-reported by physicians; and 4) files from CMS’s National Plan and Provider Enumeration System, a national Medicare file for nearly all U.S. providers.

What the Study Found

• Extensive inaccuracies were found across all four sources of information. The inaccuracy rate for phone numbers, meanwhile, ranged from 25 percent to 48 percent.
• Insurance carriers offering both MA and ACA exchanges did not report the same addresses 31 percent of the time.
• Google was the most accurate source for a provider’s name, address, and phone number.
• Directories for marketplace plans, which are machine readable, were slightly less accurate than traditional, flat-file MA directories.
• Machine-readable directories can be downloaded and used for analysis vastly more cheaply compared to flat-file conventional directories.
• Interviews with stakeholders identified reasons other than directory file type for inaccuracies. These included the low priority some providers place on maintaining correct information; a lack of consistent definitions and standards; and lack of a coordinated national approach for resolving the accuracy issue.

The Big Picture

In addition to making it difficult for health plan members to find and connect with in-network providers, inaccurate directories cause challenges for regulators charged with assessing whether health plans are meeting government standards for network breadth and adequacy. The use of machine-readable files for storing provider information offers one possible way to reduce inaccuracies. While this study found that machine-readable ACA marketplace plan directories were slightly less accurate than conventional MA directories, this is likely a reflection of the higher level of regulatory scrutiny on MA directories in comparison to marketplace directories. The authors point out that machine-readable files are the more economically effective option for identifying erroneous information in provider directories. Not only are machine-readable files less costly to download, but they also can be more easily manipulated electronically than flat files.

In addition to incentivizing health plans to adopt machine-readable directories, federal policymakers should consider establishing a federal “source of truth” for provider information, perhaps by revamping the Medicare National Plan and Provider Enumeration System (NPPES) file. There are also federal, state, and vendor efforts under way to find solutions for improving directory accuracy. For instance, New Hampshire is using claims data to determine provider information. Efforts should be made to identify best practices.

The Bottom Line

Machine-readable file formats offer an inexpensive way for health plans to efficiently identify likely inaccuracies in provider directories, but additional solutions are needed to fix the widescale proliferation of incorrect provider information.