Provider Directory Errors: More Common than you Think


Last month Federal officials warned 21 Medicare Advantage insurers with high rates of errors in their online network directories that they could face consequences if the issues are not corrected.  These consequences include heavy fines and stopping the insurers from accepting enrollments.

This action comes after the government’ first comprehensive review on the accuracy of Medicare Advantage provider directories, which members have criticized for some time. Nearly one third of Medicare beneficiaries, about 17 million Americans, are covered through HMO Medicare Advantage plans rather than traditional Medicare.

Medicare Advantage members rely on provider directories to locate in-network providers and these inaccuracies present significant access-to-care barriers and cause great inconvenience.

One Medicare plan in Virginia had the highest rate of inaccuracies among the 54 insurers evaluated. About 80% of their directory (87 out of 108 doctor entries) had errors including incorrect locations and doctors who should not have been included.

The federal review focused on reviewing primary care doctors, cardiologists, ophthalmologists and oncologists. Officials called to check on the listings for 108 doctors in each health plan. The results demonstrated that many of the directories were extremely outdated with providers who had been retired or deceased, sometimes for years.

The CMS report discovered that most health plans had inaccurate information for between 30 to 60 percent of their providers’ offices. The report pointed the finger at health plans for failing to do enough to keep their directories accurate. The main issue was a lack of internal audits and testing of directory accuracy. The number one error they found concerned doctors with multiple offices who only serve members in certain locations.

Since January of 2016 PNS has been assisting their health plan partners in keeping their provider directories up to date and reviewing provider directory requirements per CMS guidelines. The Provider Relations team has developed a process for checking in with providers every other month to verify and update their information. They make sure the directories are current, accurate and that all the doctors in the directory are eligible. In verifying and updating the provider directory every other month they exceed CMS guidelines and help the Health plans to stay ahead of the quarterly deadline.


by Carolina Diaz on February 14, 2017

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