Finding Or Choosing A Provider: What You Need To Know About Health Plan Provider Directories

by Jeanette Thornton and Matt Eyles

July 7, 2016

Health plans publish provider directories that include comprehensive listings of the physicians and other clinicians, facilities (e.g., hospitals), and pharmacies that participate in their networks. These directories, which are typically posted online and in a searchable format, are a valuable resource for individuals and their families.

Directories can help answer key questions before individuals and their families decide which health plan to enroll in or how to access care once enrolled. For example, is my primary care physician or specialist in the health plan’s network? Is the hospital closest to where I live in network? As a result, it’s essential that provider directories reflect the most current and accurate information about participating providers and facilities so that individuals can maximize the value of their coverage.

America’s health plans are committed to ensuring consumers and patients have complete and accurate information about available providers to make informed health care choices. However, our member plans’ experience demonstrates establishing accurate provider directories is a shared responsibility that requires a shared commitment from health plans and providers to ensure consumers and patients have the right information they need.

That’s why health care stakeholders worked closely with the federal government as it established requirements for what information must be included in provider directories, and in some cases like Medicare Advantage, require plans to contact on a quarterly basis the providers in their network.

While getting and keeping provider data up to date sounds simple in concept, there are some meaningful challenges to overcome. For example:

  • Data such as whether providers are accepting new patients and office hours can quickly become out of date as the number of patients in a physician practice changes.
  • Education is extremely important to ensure that everyone in a provider’s office understands what health plans that provider accepts and to ensure that consumers get accurate information when they call to make an appointment.
  • The more complex the data, the more opportunity for errors. For example, some practices have multiple locations, multiple phone numbers for each location, different office hours for each location, and temporary phone lines used for marketing purposes.
  • Because a medical group accepts a specific health plan, it does not mean that all physicians within that group do so.

The challenges of getting and keeping the content up to date are further complicated by the fact that physicians contract with multiple health plans, and unfortunately, there’s currently no unified process for updating directories. With each health plan doing this on its own, this process is time consuming and costly. It’s even more so for medical practices and hospitals, when you consider that each medical practice must work separately with each Medicare Advantage plan, Medicaid health plan, and commercial health plan with which it contracts.

So early this year, AHIP has launched a pilot program to address these challenges. The pilot is taking place in three states with 12 AHIP member health plans and has three goals:

  • Improve the accuracy of provider directories to benefit consumers regardless of whether they are covered by private insurance or public programs such as Medicare and Medicaid;
  • Reduce the number of provider calls and contacts and develop a more efficient mechanism for providers to update their information for ALL plans; and
  • Test different approaches to identify the most effective path to a potential solution at a national level.

We expect pilot results to be available later this year and will work with consumers, providers, and others to identify best practices and develop solutions based on lessons learned. We recognize these activities are crucial to improving the consumer experience in health plans, which continue to provide high-quality health care to the individuals they serve.

Jeanette Thornton is SVP of Health Plan Operations & Strategy and Matt Eyles is EVP of Policy and Regulatory Affairs at AHIP.