Accurate provider directories are essential for many reasons. Consumers need accurate information about the providers that are in their health plan network when shopping for coverage, when searching for providers and facilities that are in-network when they need care. Consumers, regulators and policy makers also need to assess provider network adequacy to assess whether they provide adequate options for consumers.
Provider network inaccuracies are common and can lead consumers to be impacted by unexpected out-of-pocket costs and surprise medical bills. Below are resources detailing the problems and potential solutions for provider directories.
Studies Detailing Problems in Provider Directories
- A December 2014 HHS Office of Inspector General report on Medicaid Managed Care found that slightly more than half of providers could not offer appointments to enrollees. About 35 percent could not be found at the location listed by the plan, and another 8 percent were at the location but said that they were not participating in the plan. An additional 8 percent were not accepting new patients. Among the providers who offered appointments, the median wait time was two weeks. However, more than 25 percent had wait times of more than a month, and 10 percent had wait times longer than two months. (Link)
- A 2015 National Health Council study evaluated the patient experience for exchange enrollees with chronic conditions and found that 79 percent of patients checked to see if their provider was in-network before picking a plan, but confusion existed between provider networks of exchange plans and non-exchange plans. 36% of patients thought it was difficult to find a list of providers. Several focus group participants reported gaps in accessing care because of confusion about the provider network when picking a plan. (Link)
- California: More than half of primary-care doctors in provider directories given to low-income patients in three counties in northern, central and southern California are not accepting new patients with Medi-Cal, the state’s low-income health plan, or could not be reached by telephone. At one plan in Butte County, more than 95 percent of the doctors listed in the printed directory were either unavailable to new patients or could not be reached. (Link)
- California: Researchers at UCSF tried contacting all 4,754 dermatologists listed in the three largest Medicare Advantage plans in 12 metro areas. Nearly half the listings were duplicates and only about half the remaining were at the listed address, accepted the plan and were offering appointments. The average wait was 45 days. (Link)
- California: A November 2014 report from the California Department of Managed Healthcare found that 12.5 percent of physicians listed in the Anthem exchange plan’s provider directory had inaccurate locations and nearly 13 percent did not take patients who had Anthem's exchange plans even though they were listed as in-network. For CA Blue Shield, 18.2 percent of doctors in the directory were not located where the insurer said they were, and 9 percent of doctors were not willing to accept patients who had Blue Shield's Covered California plans. (Link)
- Maryland: A November 2015 survey from the Maryland Women's Coalition for Healthcare Reform found that of 1,530 OB/GYN providers listed in the state’s on-line directory, just 21.9% (336 of 1,530) met three criteria: providing well-woman visits; accepting new patients; and available for an appointment in four weeks or less. In addition, 423 had inaccurate or incomplete listings, 92 were part of a closed panel, 24 were not OB/GYNs or sub specialists, and 85 were not accepting new patients. The result—only 490 (32.8%) met the criteria of accepting new patients and providing a well-women visit. (Link)
- Maryland: A January 2015 report by the Mental Health Association of Maryland found that only 43 percent of psychiatrists listed in providerdirectories in the state's marketplace could be reached; about 10 percent weren't psychiatrists; and only about one in seven were accepting new patients. (Link)
- Texas: A 2012 Texas Medical Association survey of physicians found that 62 percent of physicians had detected cases in which they were listed as participating in networks when in fact they were not. Medical and surgical specialists reported the bad listings most frequently. (Link)