81% of Entries Are Inaccurate in Provider Directories of 5 Large Payers

Most of the entries in the five large insurers’ provider directories have inaccuracies, a research letter published in JAMA Open Network explained.

The researchers compared physician information in the Medicare Provider Enrollment, Chain, and Ownership System database to the same physicians’ information in the directories of five of the largest insurers in the US. The insurers were Aetna, Elevance, Cigna, Humana, and UnitedHealth. Almost 450,000 of the nearly 635,000 physicians in the Medicare database were in multiple directories.

“A physician’s information was considered consistent if it was the same among all locations or specialties across all directories in which the physician was found,” the letter explained. “A physician’s information was considered inconsistent if physician address or specialty differed across directories or if a physician was found in a directory but an address or specialty present in other directories was missing from that directory.”

Eight out of ten entries for the study’s population had inaccuracies, the researchers found. A fifth of the physicians who were in multiple directories had the accurate site and specialty information across the materials (19.4 percent).

Overall, specialty information was more likely to be accurate than location information. Over two-thirds of the physicians’ specialty information was accurate across all of the directories (67.8 percent). In contrast, 27.9 percent of the physicians had consistently accurate addresses.

The accuracy rate was higher for physicians with only one practice address. Among this subpopulation, 84.8 percent of the addresses were correct as well as 68.6 percent of the specialty information.

Regarding consistency of address and specialty data, providers that were in five directories were more likely to have the wrong information. Only 7.8 percent of providers in five directories had correct address and specialty information across all five resources. Thirteen percent of providers in five directories had consistent address information and 58.7 percent had consistent specialty information.

In separate studies, one of the primary causes of inaccuracies in directory data was that group practices shared the information for all of the physicians at every location. Such a reporting procedure fails to take into account providers’ individual practice locations.

Inaccurate provider directories can lead to surprise billing, access to care barriers, and network adequacy estimate challenges and misrepresentation.

“This study’s findings highlight the need for unified technology-enabled solutions, such as that proposed by the Centers for Medicare and Medicaid Services, which is seeking to create a single, centralized physician directory using modern interoperable formats,” the researchers concluded.

Health plans are required to maintain their provider directories in accordance with the No Surprises Act. This helps to assess network adequacy.

There are a number of strategies that payers can pursue to ensure that the provider directory data they are collecting is accurate. Health plan-provider transparency is key. Providers can submit the addresses where they most frequently see patients.

However, as the research letter pointed out, the financial strain that directory reporting places on providers ($2.75 billion) and the lack of a standard for payers create roadblocks for progress on this issue.