Editor's Note: In the 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, they often turn to provider directories—electronic or printed lists of physicians, hospitals and other healthcare providers in each health insurance carrier's products.

In a new report prepared for the California HealthCare Foundation, summarized below, Manatt Health examines policy, operational, business and technical challenges and solutions to well-functioning, integrated provider directories and how they have been overcome in four states—Colorado, Maryland, New York and Washington. The report 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 policymakers and stakeholders as they seek to improve consumer access to accurate provider directories. To download a free copy of the full report, click here.

Since implementation of the ACA, more consumers are shopping for health insurance through the individual commercial market. Many of these consumers are obtaining insurance for the first time and must navigate a complex coverage market and make important decisions for themselves and for their families based on available information.

Some carriers, state Medicaid agencies and SBMs publish provider directories to inform consumers as they select, enroll in, and use carriers' products. Organizations that offer multiple products across multiple carriers, such as SBMs, may publish integrated provider directories—online databases of carrier and provider data which consumers may search based on a set of criteria, such as provider name and location. Some state Medicaid agencies and SBMs do not publish provider directories but instead point consumers to online provider directories that carriers maintain.

Consumers use provider directories to:

  • Evaluate coverage options to determine whether a healthcare provider they would like to use is in-network and would be covered.
  • Select products based on cost, network size and care options.
  • Identify and locate providers when seeking care.

A March 2015 survey by Consumer Reports National Research Center found that 78% of privately insured Americans used their carriers' online provider directory in the past two years to find doctors, facilities or both.1

Despite the availability of provider directories, it is widely acknowledged that directories often contain inaccuracies. Directory errors may lead consumers to seek care at the wrong address, or worse, consumers may learn that the health insurance product they purchased does not cover a specific provider they want to see or are already seeing, despite being listed in the directory. This is troublesome because consumers may be required to pay significant fees to cover their visits to out-of-network providers.

Methodology

To determine which states to include in the provider directory study, Manatt took a three-step approach:

  1. Manatt conducted research to identify SBMs with functioning, integrated provider directories that were accessible from the marketplace's website and returned search results.
  2. Manatt researched carriers and state Medicaid agencies in target states, and conducted a literature review and stakeholder interviews. Manatt interviewed 32 stakeholders representing consumer advocates, SBMs, state Medicaid agencies, regulators, carriers and providers.
  3. Manatt and the California HealthCare Foundation convened a small group of stakeholders and subject matter experts to guide the project's approach and provide feedback on key findings.

Highlights of Major Findings

1. Policies, regulations and enforcement

Lack of enforcement of regulatory and contractual requirements creates an environment that does not foster shared accountability.

Developing and maintaining provider directories involves many actors, including carriers and marketplaces, physician practices and clinics, hospitals, independent practice associations (IPAs), hospitals and other institutions. Over time, these actors develop their own processes and requirements for creating and updating the information in the directories.

Manatt found that all carriers, marketplaces and state Medicaid agencies have contractual language requiring accurate and timely provision of provider directory data. These requirements are passed through carriers to medical groups, providers and institutions.

In addition to specifying data requirements, contracts describe penalties or remediation measures if a party fails to comply. Stakeholders report, however, that penalties are generally not enforced, primarily out of concerns for compromising robust provider networks and the mutual interests of state Medicaid agencies, SBMs and carriers to minimize disruption of member services. New York stakeholders were the only interviewees to report enforcement of penalties by the state for failure to maintain accurate directories.

2. Data standards

A lack of uniform data standards and accompanying guidance results in unusable data, especially when data comes from disparate sources.

Research and stakeholder interviews suggest that, in most states, there is minimal coordination or collaboration to standardize and streamline processes that could make directory updates easier and more efficient. In New York, the state and health insurance marketplace are working together to streamline carrier reporting of provider information through a common template accompanied by standards.

Carriers that operate nationally or in multiple states have the challenge of maintaining separate reporting processes for their respective markets in the absence of national or widely accepted industry standards. Several carriers noted that complying with disparate requirements is burdensome and requires significant resources.

3. Data integrity

Efforts to audit, perform quality assurance and verify the accuracy of provider directory data vary widely, with many organizations performing little to no quality review.

Despite the significant need for deliberate and ongoing efforts to ensure data integrity, few carriers, marketplaces or state Medicaid agencies report conducting robust data reviews of quality assurance activities. Almost all marketplaces and some carriers report provider information as they receive it and perform little to no quality checks or data reconciliation. (Some seek to verify data using existing databases but typically do not change data found to be incorrect.) This approach may result in multiple entries for the same provider due to differences in carrier naming conventions (i.e., Dr. John Smith, Dr. J. Smith and Dr. John H. Smith).

A few SBMs and carriers attempt to clean the data, using identifying information, such as the provider's national provider identifier (NPI), address, date of birth or state licensing number to reconcile the disparate information that carriers submitted and create a single record for each provider. Even when data are cleaned and reconciled, however, significant limitations remain, because organizations do not have access to a single source of provider information and may not be able to resolve all provider records successfully.

In addition to data reconciliation, some marketplaces, state Medicaid agencies and carriers make an effort to verify provider information through routine or ad hoc audits. For example, when an issue is reported to a marketplace or state Medicaid agency, it or its vendors may reach out to the provider directly to confirm information and contract status. If the marketplace or agency identifies an inaccuracy with the providers information, it typically works with the carrier to correct the information for the carrier's next data submission rather than correct the information in its systems to reflect a real-time update.

4. Time and resource requirements

Organizations typically rely on time and labor-intensive manual processes to develop and support provider directories.

All of the carrier, marketplace and state Medicaid agency stakeholders interviewed for this project reported investing time and resources in creating and maintaining provider directories. To a large extent, processes and systems rely heavily on manual efforts to verify and update provider data. Many use a combination of manual and electronic processes to collect and publish data. All marketplaces and carriers that were interviewed report contracting with third-party vendors to augment their internal provider directory resources and perform functions that the organizations do not have the capabilities to accomplish in-house.

Stakeholders acknowledge that resource limitations constrain their abilities to improve processes and systems devoted to maintaining provider directories. This is most apparent among marketplaces and states that rely on federal or public funding sources. It is a growing concern as marketplaces transition to becoming self-sustaining in 2016 and beyond.

5. Consumer decision making

Provider directories do not currently serve to effectively engage and inform consumers as they enroll in coverage and seek care.

Even though SBMs were not required to implement provider directories under the ACA, several took the initiative to do so to help consumers as they purchase and enroll in coverage. While there was not consensus regarding the data elements required to create a directory with an adequate level of information to support consumer decision making, stakeholders agree that the following data elements are valuable:

  • Name
  • Address
  • Phone number
  • Open/closed panel (specific to product)
  • Gender
  • Languages spoken by provider and office staff
  • Specialties
  • Accessibility
  • Hours of operation
  • Admitting privileges/affiliations

Some stakeholders also feel that facility information is important, especially to Medicaid populations who may be used to seeking care at a specific clinic rather than with a particular provider.

6. Provider contracting

Confusion exists among providers about contracting and participating in specific carrier products and the requirements and processes needed to update provider data.

Stakeholders reported a general lack of awareness among providers with respect to certain carrier contracting practices, which can result in confusion between providers and members seeking their services. Interviewees pointed to the need to educate providers and their staff about the importance of updating their information and communicating changes to carriers in a timely manner.

Carriers reported using the contracting process, existing network management relationships, newsletters and other marketing opportunities to educate and remind providers about their obligations to update and communicate changes to their information under their contracts. Marketplaces expressed interest in implementing provider-facing portals where providers, after proving their identity, could verify and correct their information.