Provider Directories: Litigation, Regulatory, and Operational Challenges

Since the implementation of the Affordable Care Act (ACA), millions of consumers have signed up for health insurance coverage through the Health Insurance Marketplace. Additionally, employer groups both large and small are increasingly asking health insurers to create health insurance products specific to their  employees. As a result, health plans are creating new, contracted network offerings at an unprecedented rate. These health plan networks range from higher-cost PPO products with broad provider networks to products with narrow or tiered networks that boast lower premiums but provide limited choices of providers.

As the volume and variety of health insurance products increase to accommodate an expanding market, so do concerns about whether the contracted provider networks adequately serve their target patient population. Further, some consumers have complained that the provider network information provided to them by health plans is misleading and inaccurate. As a result, federal and state regulations have added more specificity around what constitutes an adequate provider network and have defined the information that a health plan is required to provide to consumers.

These regulations require health insurers to maintain and provide consumers with an accurate listing of providers—both facilities and physicians—participating in their networks. This includes information about their location, specialty, hospital affiliation, and languages spoken. Consumers are entitled to have access to these provider directories both in hard-copy printed format and via a Web-based provider search portal on a health insurer’s website. Although these regulations are intended to ensure that consumers are relying on accurate provider information, recent studies and reports indicate that health plans struggle to maintain accurate provider directories.

The repercussions of inaccurate provider directories can be significant, posing risks to both consumers and health plans. Inaccurate directory information may limit a consumer’s ability to verify if a preferred doctor is in-network or to know how many and what types of providers would have to be accessed under a particular product offering. Additionally, the consumer may be at risk of being charged higher out-of-network rates when providers are erroneously listed as being in-network. These inaccuracies also put health plans at greater risk of litigation, government penalties and investigations, and significant administrative costs associated with rectifying inaccurate directories.

The primary purpose of this white paper is to provide health plan stakeholders with information on provider directories. These stakeholders include the executives, managers, and analysts within health insurance companies that evaluate provider network contracts, in addition to those directly involved in maintaining the company’s provider directories. The first section of the paper includes a critical review of the guidelines and regulations around provider directories. The next section discusses some of the operational challenges that health plans encounter in maintaining accurate provider directories. This is followed by an assessment of the risks posed by inaccurate provider directories to both consumers and health plans. The paper concludes with a case study and a discussion of the future of provider directories, including the recent guidance from the Centers for Medicare and Medicaid Services (CMS).