A provider directory is list of in-network healthcare providers, generally provided by an insurer, to help enrollees find in-network care. Consumers use provider directories at the point of health plan shopping to ensure that doctors they already have are in-network and as a tool when they need to identify a new healthcare provider for care. Consumers, regulators and policymakers use provider directories to assess provider network adequacy.
Inaccurate or out-of-date provider directories curtail a consumer’s ability to find in-network providers, potentially increasing their costs significantly.1 If consumers do not have an accurate list of in-network providers, they may incur out-of-network costs in the form of surprise medical bills, having seen a provider they believed was in-network. Indeed, a 2018 survey found that over half of physicians reported that their patients faced coverage issues due to provider directory accuracy issues.2
Myriad studies have shown that provider directories suffer from high rates of inaccuracies:
The federal government has minimum standards for private health plans sold on the ACA Marketplaces, requiring them to update their provider directories monthly and collect up-to-date information from providers quarterly.9 Several states have rules requiring more frequent updates to online provider directories and/or apply those rules to more types of health plans. While update requirements are helpful, they may not be enough to protect consumers if health plans don’t also take steps to ensure the accuracy of the information, such as:
The National Association of Insurance Commissioners has a model law that includes a mechanism for the public to report directory inaccuracies to health plans and a requirement that insurers periodically audit their directories.11 Additionally, this model law includes continuity of care protections for patients who are in the middle of an active course of treatment if their providers leave or are removed from their health plan’s network. Though the consumer-friendly features of this model law make it a useful tool improve the accuracy of provider directories and protect consumers, most states have not adopted this model language.
1. Families USA, "10 Steps to Improve Provider Directory Accuracy."
2. O'Rielly, Kevin B., "Directory-Related Mishaps Affect Patients Monthly, Say Doctors," American Medical Association (April 30, 2018).
3. Busch, Susan H. and Kelly A. Kyanko, "Incorrect Provider Directories Associated with Out-of-Network Mental Health Care and Outpatient Surprise Bills," Health Affairs, Vol. 39, No. 6 (June 2020).
4. Luthi, Susannah, "Medicare Advantage Provider Directories Still Riddles with Errors," Modern Healthcare(December 4, 2018).
5. Department of Health and Human Services, "Access to Care: Provider Availability in Medicaid Managed Care," (December 2014).
6. Resneck, Jack S. Jr., et al., "The Academy of Dermatology Network Physician Directories Posted by Medicare Advantage Health Plans in an Era of Narrow Networks," JAMA Dermatology, Vol. 150, N. 12 (December 2014).
7. Maryland Women's Coalition for Healthcare Reform, Website Home Page.
8. Maryland Women's Coalition for Healthcare Reform, "Network Adequacy in Maryland: A Report on Provider Directories and Women's Access to Health Care Services," (November 2015).
9. National Association of Insurance Commissioners, "Network Adequacy," (April 18, 2019).
10. Families USA, "Improving the Accuracy of Health Insurance Plans' Provider Directories," (October 2015).
11. National Association of Insurance Commissioners, "Health Benefit Plan Network Access and Adequacy Model Act," (2015).