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Improving Health Plan Provider Directories

Patients rely on a variety of sources to find the care they need from the clinicians they prefer. These include search engines, doctor rating sites and referrals. Among the more common resources that patients use are health plan provider directories which, according to two surveys conducted in 2020, more than half of patients use to select a physician.

Despite industry efforts, the accuracy of health plan provider directories is a persistent challenge. Recently, the American Medical Association and CAQH released a white paper analyzing the current state of the provider directory problem, identifying best practices and recommending practical approaches that both health plans and practices can take to solve the problem.

The Situation:

  • Most patients use health plan provider directories to make decisions on insurance coverage and to seek and select clinicians to provide healthcare services.
  • The accuracy of these directories has been a longstanding problem and, despite significant efforts, minimal improvement has been observed.
  • Patients encountering inaccuracies in health plan directories can experience delays in access to care and unexpected out-of-pocket expenses.
  • Regulators and legislators continue to introduce new requirements aimed at improving the accuracy and timeliness of directories

The Solution:

  • The root causes of the problem must be understood, and solutions need to be employed that align and position stakeholders to address them.
  • This requires a recognition of shared responsibilities and a commitment to streamlining the process for patients to find in-network care. These responsibilities include:
    • Health plans streamlining data update channels and providing practices with a way to differentiate between locations where a clinician is seeing patients versus one where he or she is contracted but not regularly seeing patients.
    • Practices providing timely and accurate updates when key directory data, such as office address and phone number, change and associating clinicians to practice locations where they regularly see patients as opposed to registering every clinician at all possible practice locations in the event they are covering for colleagues.
  • Voluntary standards must be adopted for provider directory data quality, governance and interoperability that will position health plans and practices for success.

Previous efforts to improve directory accuracy have been stymied, in part, by a lack of shared understanding and responsibility between clinicians and health plans and a lack of data standards and fragmented systems to collect and transmit this information. This is exacerbated by already burdensome administrative requirements. By working together, health plans, clinicians and practices now have an opportunity to solve this persistent problem for patients once and for all.

To read the full report, click here or, download the on demand webinar