Dive Brief:
- Bipartisan legislation passed in 2020 to shield consumers from unexpected medical bills, the No Surprises Act, included provisions meant to force health insurers to clean up their provider directories. But those directories are still highly inconsistent, new research suggests.
- Researchers at the University of Colorado School of Medicine used artificial intelligence to analyze health plan provider directories for over 40% of U.S. physicians, and found inconsistencies for 81% of doctors across five major insurers, the study published in JAMA said.
- Most of the inconsistencies were among addresses among physicians listed as practicing in multiple locations. That’s in line with prior research suggesting many address errors stem from group practices reporting all doctors at all practice locations to insurers, regardless of which location the physician actually practices.
Dive Insight:
The No Surprises Act is meant to protect consumers from being on the hook for unexpected medical bills and went into effect in January 2022. Many of those bills stem from patients receiving care from a clinician they believe is in-network who isn’t actually covered by their insurance.
That can hinge on the accuracy of physician directories maintained by health insurers. Numerous pieces of research have found such directories can be peppered with inaccurate contact or location information, contain duplicates and include out-of-network providers.
A CMS review of Medicare Advantage directories from 2018 found inaccuracies ranging from 5% to 93% of all listings, depending on the plan examined.
The federal government has directory accuracy regulations in place for Medicare Advantage, Medicaid and marketplace plans, and some states have taken action to improve directory quality. Slightly more than half of states have quantitative network adequacy standards.
No Surprises includes numerous requirements for payers to maintain, verify and update physician directories to keep them accurate and up to date.
To see whether directories had improved since No Surprises passed, researchers at the University of Colorado School of Medicine used algorithms created by HiLabs, a Maryland-based healthcare AI company.
Researchers crosschecked physician information in Medicare’s database with physician directories maintained by UnitedHealth, Elevance, Cigna, Aetna and Humana to compare the consistency of street addresses and specialty.
Of the almost 450,000 doctors found in more than one directory, just 19% had consistent address and specialty information. Almost 28% had consistent practice location addresses. Specialty information was more reliable, as 68% of physician entries across directories had consistent specialty information.
Information got less consistent if physicians were in more insurers’ directories, researchers found.
Beyond causing unexpected bills for consumers, inaccurate directories can also lead to care delays, challenges in regulatory oversight of payer network adequacy and false advertising of a network’s robustness as consumers select health plans, researchers said.
The findings “highlight the need for unified technology-enabled solutions,” like those proposed by the CMS, the study concluded. In October, the CMS issued a request for information on the agency’s plan to establish a national physician directory that can be a “centralized data hub” for directory information across the U.S., according to documents in the Federal Register.
Health insurers argue that it’s difficult for them to maintain directories, due to frequent changes to information and a lack of standardization.
Administrative burden on doctors also plays a role. Sending directory updates to insurers costs practices a collective $2.8 billion annually, according to the California Association for Healthcare Quality.
