Simply put, a provider directory is a list of physicians in an area and within an insurance plan. People use that information when they need care to find a local doctor that takes their insurance and is also accepting new patients, so the information needs to be accurate.
Health plans also create directories to help members decide which insurance product to sign up for during open enrollment periods, so members can ensure that their preferred doctors accept the plan they choose.
The information in health plan provider directories is often inaccurate, with common errors including wrong phone numbers, provider not at listed address, incorrectly listing in-network providers as accepting new patients, and provider omissions.
There has been increased attention given to provider data management and an attempt to ensure health provider data accuracy. There are federal and state regulations to address provider data accuracy that can lead to monetary penalties for health plans for these errors. In addition, consumer watchdog groups can target health plans with lawsuits, seeking to recover damages caused by incorrect provider rosters.
Health plans often update provider data annually as part of the contract and credentialing process with providers, using this information in their provider directory management process. However, this procedure takes time, especially if providers are having to update information for every health plan they are affiliated with, and sometimes the information does not conform to the data structure required by the health plan.
For example, a health plan may ask a provider if they are taking new patients with a response choice being yes or no. This question does not capture nuance so the answer will show up as a no when the provider may be taking patients as long as they have a particular medical condition or meet certain criteria.
Provider directories are an essential lifeline for health plan members who need to identify and contact in-network providers for their health and well-being.
CAQH DirectAssure improves the quality of provider data in health plan directories by simplifying the data collection and evaluation process. Learn more.