Inaccurate Provider Directories May Spark Surprise Medical Bills

Inaccurate provider directory information can leave mental healthcare patients paying for out-of-network providers and facing surprise medical bills, a recent Health Affairs study found.

“Patients use directories to locate an in-network provider or to determine whether a specific provider is in the plan’s network,” the study stated. “Patients’ use of inaccurate information in directories may result in frustration, delays in care, the inability to locate a participating provider with available appointments, mistaken use of an out-of-network provider (that is, the receipt of a 'surprise bill'), or the purchase of a plan without a preferred provider.”

Having poor or inaccurate data in a mental healthcare provider directory has ramifications even beyond affecting patient care.

“Regulators, accreditors, and purchasers may rely on directory information to determine whether a plan has an adequate network,” the study also pointed out.

The researchers surveyed privately insured patients who use outpatient specialty mental healthcare to discover their experience with inaccuracies and the effects of that discovery.

Most of the participants were non-Hispanic white, between the ages of 18 and 34. Around one in three had experienced serious psychological distress. Those who had been in psychological distress were 9 percent more likely to use a directory.

The survey revealed that 44 percent of the patients used a mental health provider directory to locate a provider in their insurance network.

Of these, 53 percent came across incorrect information in the directories they used. The patients reported a number of potential issues, most commonly a provider being listed as taking on new patients, a provider being listed as in-network when the provider did not actually accept the patient’s insurance, and inaccurate contact information.

The impact of these inaccuracies was stark. Double as many of the patients who came across inaccuracies ended up receiving treatment from an out-of-network provider. These patients were also four times more likely to be hit with surprise billing through an outpatient, out-of-network bill.

Nearly three out of four patients who experienced a directory inaccuracy did not report it. Of the 28 percent who did report it, there was wide variance about to whom they directed their complaint. Most of them called their insurance company and reported it to an employee. Some sent in a formal complaint to the healthcare payer and only three percent filed a complaint with a federal agency.

“While mental health provider shortages may make it difficult for plans to maintain mental health networks that meet network adequacy requirements, accurate directory information seems fundamental to the most basic level of patient engagement and access,” the study stated.

The researchers laid out three recommendations to reduce the risk of directory inaccuracies leading to out-of-network selection and surprise billing.

First, the researchers called for the federal government to establish clearer standards for directories. Second, the researchers urged that the existing legislation requiring healthcare payers to keep their directories up to date be more strongly enforced. Last of all, the researchers suggested adding more regulators to oversee directory accuracy.

The challenge of keeping  in-network provider directories upodated is nothing new.

“It isn’t because health plans and provider organizations don't care – they do,” Eyal Gurion, Senior Vice President, GM Symphony Provider Directory, told HealthPayerIntelligence. “But every health plan has invested in multiple solutions, systems, and portals with their provider networks, and this makes things complicated. If I'm a provider and I contract with 15 or 20 health plans, I might need to accommodate 15 or 20 different processes, formats, and requirements.”

Blue Shield of California and the California Department of Managed Health Care joined forces with the Integrated Healthcare Association (IHA) and in early 2019 released the Symphony Provider Directory, a centralized system for healthcare payers and providers to coordinate directory information. The organization’s goal is to reach 80 percent of California’s health plan and providers by 2023.

Blockchain initiatives, such as Cigna and Sentara Healthcare’s initiative or the Aetna, Anthem, HCSC initiative, has also been employed to keep data accurate.