Directory Assistance: Maintaining Reliable Provider Directories for Health Plan Shoppers

Manatt Health


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In this post-Affordable Care Act (ACA) era, many consumers are making health coverage decisions for the first time and in new ways. To inform their decisions, many consumers turn to provider directories — electronic or printed lists of physicians, hospitals, and other health care providers in each health insurance carrier’s products.

Inaccurate provider directories can lead to consumer frustration and confusion, and result in substantial out-of-pocket costs for consumers who may unintentionally seek and receive out-of-network care. Yet it has proven challenging for organizations — carriers, state Medicaid agencies, and ACA-created insurance marketplaces — to maintain accurate and up-to-date provider directories.

This report examines policy, operational, business, and technical obstacles to well-functioning, integrated provider directories and how they have been overcome in four states: Colorado, Maryland, New York, and Washington. It details the perspectives and experiences of consumer advocates, carriers, providers, state-based marketplaces (SBMs), and state Medicaid agencies in those states, with the goal of informing California policymakers and stakeholders as they seek to improve consumer access to accurate provider network information.

Among the report’s findings:

  • An environment for shared accountability can be fostered through incentives, policy alignment, and enforcement of regulatory and contractual requirements.
  • Creation of uniform data standards and accompanying guidance can help ensure that data are usable, especially when they come from disparate sources.
  • Efforts to audit, perform quality assurance, and verify the accuracy of provider directory data vary widely, with many organizations performing little or no quality review.
  • Organizations typically rely on time- and labor-intensive manual processes to develop and support provider directories.
  • Provider directories should engage and inform consumers with diverse language needs and educational levels as they enroll in coverage and seek care.
  • Providers need clear information about contracting and participating in specific carrier products and the requirements and processes of updating their data.

The full report is available under Document Downloads. A webinar held in July 2015 also provides an overview of findings.