How to fix persistent issue of inaccurate health plan directory

As patients use a variety of search engines, physician rating websites, and social media platforms to find physicians who meet their needs, they often turn to health plan directories to take the final decision. Patients rely on directories to identify clinicians based on specialty, location, hours, and health plan participation. They also consult directories for information on languages ​​spoken, special skills and experience, availability of telehealth or LGBTQ+-friendly services.

But too often the directories contain erroneous or outdated information. This can lead to patient frustration, delays in care or unforeseen disbursements. In fact, a 2020 Health Affairs The study titled “Incorrect Provider Directories Associated With Out-Of-Network Mental Health Care And Outpatient Surprise Bills” showed that 53% of patients seeking such care in health plan directories found inaccuracies. Centers for Medicare & Medicaid Services audits of online Medicare Advantage plan directories found similar error rates.

This problem has persisted despite efforts by policy makers and health plans to address it.

A new document from the AMA and CAQH highlights the need for alignment between health plan and physician practice, automation and a streamlined process to produce accurate directories. It also highlights the issues and recognizes the responsibilities of the players serving patients.

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Health insurance plans rely on physician practices to notify them of changes in practice information. Although it sounds simple, practices contract with more than 20 plans on average and can be inundated with requests for updates by phone, email, or health plan-specific portals. Some medical practices also report that the updates they provide do not always appear in directories.

Problems also persist because practice information changes frequently, increasing the possibility of errors. Studies show that between 20% and 30% of directory data changes every year.

Finally, the newspaper explains that no party is the exclusive holder of this information. Doctor’s offices maintain contact information and the group list, but health plans control information about doctors on contract and often locations covered by the contract. Information about which doctors are accepting new patients covered by which health plan, meanwhile, is controlled by both parties.

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The AMA and CAQH outline solutions to ensure patients have access to accurate information in health plan directories.

The paper asks:

  • Identify the respective responsibilities and the best approaches to fulfill these responsibilities.
  • Establish data governance standards that incorporate legacy data silos.
  • Identify greater opportunities to streamline health plan data requests so that practices can deliver data through fewer and more consistent update channels.
  • Harmonize data systems to facilitate better quality data and facilitate the development of bulk and real-time updates.
  • Agree on a minimum set of repertoire data and accept shared responsibility for producing, managing and presenting accurate data to patients.

The article concludes that past efforts to improve the accuracy of directories have been hampered, in part, by a lack of shared understanding and accountability between clinicians and health plans, a lack of data standards, and fragmented systems. to collect and transmit this information. This situation is exacerbated by already burdensome administrative requirements. By working together, health plans, clinicians and practices now have the opportunity to solve this problem for patients once and for all.

Learn more about what the AMA is doing to make network directories accurate and accessible.

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