Recent regulations do little to alleviate physician roster issues

Finding a physician using directories of paying physicians remains a daunting task.

I consider myself a capable person with several years of experience working for one of the nation’s largest healthcare payers, but even I can’t effectively use a payer’s online provider directory for find a doctor. I’m not alone. Consumer frustration with payer provider directories leads to low member satisfaction, poor payer ratings, and unnecessary administrative costs to resolve complaints. To protect consumers, regulators are working to improve the consumer experience by holding payers accountable for the accuracy of their provider directories. However, a fundamental disconnect exists between regulators and consumers around the goal of a payer directory. With today’s technology, consumers are more likely to use Google to find a doctor than to use their payer’s directory. Regulators need to better understand consumer needs before setting policies to ensure they will bring about meaningful change.

Supplier Directories: A Low-Value Burden

On December 27, 2020, the No Surprises Act was signed into law with the primary purpose of eliminating surprise billing. Built into the law with no surprises is a 90-day “verification” process that does little to address the pervasive issues that affect the accuracy of the Payer Provider Directory. Although the final rule is still pending, the legislation requires payers to verify and update their provider directory at least once every 90 days with emphasis on network participation status, name, l address, specialty, telephone number and numeric contact details of the provider.

Ideally, the paying provider directory would be used to support two use cases: confirming the provider’s network participation status and finding care. Like most Americans, I rarely have reason to search for a provider I’m already receiving care from in a payer’s provider directory. I just want to know that the insurance I used before is still accepted or that my new insurance will be accepted by my current provider. When seeking care from a new provider, I need a little more information. I want to know which providers are closest to me, which ones offer the type of care I’m looking for, which ones I can get an appointment with, and which ones are “better” than others. Regulators have skewed directory requirements in favor of the “find care” use case to help consumers. However, regulators fail to recognize that payers simply cannot compete with search engines like Google and continue to push legislation to address the consumer experience issue, but payers will never be able to succeed in this space.

Regardless of the use case you envision, managing vendor directories is an administrative burden for payers and vendors. While a directory is necessary for payers looking to recruit members based on their contracted network (our first use case) and help connect members seeking care to network providers (our second use case) use), directories are not high value products for the community provider. Although consumers use directories to find care, providers believe it is not a high-impact marketing tool for recruiting members and prefer to rely on word of mouth, search engine results research, print advertisements and television advertisements. Without direct interest from the provider community or penalties that can be attributed to providers’ failure to maintain their directory data, payers will continue to fail to meet directory accuracy standards. The no-surprise statutory 90-day verification period does little to hold vendors accountable for maintaining the accuracy of their data, as it imposes no meaningful consequences on the vendor who fails to do so. Although the final rule on the legislation is still pending, historically CMS has done little or nothing to hold providers accountable for the data they provide to payers for directory use. In the past, CMS sought to penalize payers for the directory’s lack of accuracy. The lack of impact this has had on consumers is evident as the need to improve the accuracy of directories continues to be an issue to be addressed.

Regulations require payers to publish accurate provider directories. But are they relevant? A 2020 patient search behavior survey by Yext compiled results from 12 months of research and found that 71% of members initially use a search engine like Google, Bing or equivalent to find care and only 21 % initially use a directory of paying providers. The Yext survey further establishes that once a member selects a provider, 42% of members then use their payment website, likely trying to determine network membership status. I can identify with that. When I had trouble using my health care payer’s directory, I also turned to a Google search to get what I needed. There is an emergence in the healthcare IT space where organizations like WebMD and Healthgrades are developing technology to connect patients and doctors based on their specific healthcare needs. Additionally, as regulators push in multiple directions to make data more accessible, these healthcare IT companies may enable features on their websites to show which insurance plans each physician accepts. As these health informatics companies and search engines develop solutions to meet consumer needs, the payer’s provider directory becomes increasingly useless.

Precise and complete service provider: in search of the Holy Grail

A payer’s ability to succeed in the area of ​​vendor data accuracy is limited by several factors, including conflicting regulations, system limitations, and a lack of input from the vendor community. Although payers often find solutions to overcome conflicting regulations and system limitations, they rely heavily on providers for the data itself. Obtaining an accurate and complete set of data from every vendor is so difficult that many payers have shifted to an “all we can get” mindset where they gladly accept vendor information in any state in which they can be provided. Lack of updates and inconsistent formatting vendor data entry errors that impact consumers.

Payers and providers talk about the benefits of a national trade repository to reduce administrative burden and theoretically improve quality, but without a mandate from regulators it has never materialized on a national scale. California State Bill 137 attempted to centralize and standardize vendor directory requirements, but 7 years after the law was signed, no measurable improvement in the consumer experience has been realized. While in theory creating a central repository for supplier directory data has its merits, buy-in from the supplier community and a commitment to regularly updating their data is critical to success.

Although one might think that supplier directory data is not very volatile and difficult to maintain, 2021 research from LexisNexis®Risk Solutions shows that approximately 33,000 supplier addresses, 1,750 telephone numbers and 3 300 names change every week across all vendors in the United States. Even harder to track than addresses, phone numbers, and names are new patient acceptance indicators that can change daily at the provider level, address level, and network level (Medicare HMO, Commercial POP, etc.). Knowing that this specific indicator is a key factor in a provider showing up in a payer’s directory due to regulations, its lack of maintenance can be quite impacting on the consumer experience. With this level of volatility in the data set, payers are constantly chasing a moving target and unfortunately failing.

A pervasive problem that reduces the accuracy of provider directories stems from the tendency of the provider community to over-allocate which physicians are in which locations to hedge their bets with claims-paying activity. Getting paid by the insurer is the primary concern in the provider’s relationship with the payer. Because many claims payment systems require a pre-existing link between physician and service location, providers have learned that assigning each physician to each practice location results in the highest success rates for payment. complaints. This over-attribution practice also has the added benefit for providers looking to reduce the administrative burden of tracking which physicians operate from which locations and when. When payers use the same system for claims payment and provider directories, this results in incorrect display of providers at locations, which reduces the consumer experience and hinders a payer’s ability to meet standards. directory accuracy.

Consumer experience is a priority in the industry, but regulators are missing the mark with their “90-day verification” mandate in law unsurprisingly. They have created an additional administrative burden for payers and providers who will likely see a high volume of non-compliance unless the final rule institutes heavy penalties for payers and providers. Consumer frustration will remain high as the primary need to see if their chosen provider accepts their insurance through the payer-provider directory remains a gap. Regulators should spend time understanding the industry’s tendency to turn to health IT companies and search engines to find care as the best solution. In addition, payers should support healthcare IT companies and search engines with indicators to display a provider’s plan membership status creating a one-stop quality experience for the consumer.

Lianne Eberle is Senior Director of Healthcare Strategy and Provider Data at

LexisNexis Risk Solutions.

About Geraldine Higgins

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