Provider Directories: Litigation, Regulatory, and Operational Challenges | 2018 Update

Since the implementation of the Affordable Care Act (ACA), millions of consumers have signed up for individual health insurance through the Centers for Medicare and Medicaid Services (CMS) 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 range from higher-cost preferred provider organization (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 insured population. Further, some consumers have complained that the provider network information provided to them by health plans is misleading and inaccurate. Lawsuits have been filed against health plans making these allegations. 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.

Read the full paper.