Patients rely on provider directories published by health insurers to find doctors. However, the directories are not always reliable, according to a new study by researchers at the University of Colorado School of Medicine.
The study – published in March in the Journal of the American Medical Association – is the latest evidence of a persistent problem with provider directories, one that federal regulators have been trying to stamp out.
The directories often contain inconsistent information, meaning, for example, that a doctor’s address and specialty may vary from directory to directory. Conducted in December 2022, the new study found significant inconsistencies between the online provider directories of five major health insurers: Aetna, Cigna, Elevance Health, Humana and UnitedHealthcare.
The federal No Surprises Act – designed to curb unexpected medical bills – generally requires provider directories to be accurate. It’s not just a matter of convenience. Patients could be hit with surprise bills for out-of-network care if a directory leads them to believe mistakenly that a provider is in-network.
Under the law, providers must refund patients who inadvertently receive out-of-network care due to inaccurate information in a provider directory. The law also allows providers – through contracts – to shift the financial burden to insurers.
“That’s a chunk of surprise billing. It’s not the bulk of it, but that certainly affects it,” said Dr. Neel Butala, a co-author of the study and a co-founder of HiLabs, a Bethesda, Maryland-based healthcare data technology company. Butala is also an assistant professor at the University of Colorado medical school.
HiLabs, which works with insurers to clean up provider directories, provided technology services for the research. The company aggregated publicly available data across providers, then worked with the researchers using natural language processing to compare addresses and specialties across different sources.
For their research, Butala and his co-authors combed a database that included nearly 635,000 physicians in the U.S. Roughly 450,000 appeared in more than one directory. The more directories in which doctors appeared, the greater the inconsistencies in their addresses and specialties. For doctors in two directories, 28.6% had consistent information across directories. For those in five directories, the figure was down to just 7.8%.
There also were more inconsistencies for doctors practicing at multiple locations than at single locations, according to the study, which attributed the discrepancies to practices reporting all doctors practice at all locations regardless of each individual doctor’s location. The findings are consistent with previous research on the issue, Butala said.
In an interview, Butala said neither providers nor insurers are ultimately to blame. as they both face challenges in ensuring data is accurate. Insurers cope with frequent provider changes and lack of a uniform standard for reporting information, while medical practices deal with conflicting technologies, schedules and formats for submitting data. A study by the Washington, D.C.-based Council for Affordable Quality Healthcare pegged the administrative costs for providers at nearly $2.8 billion a year, or just under $1,000 per practice.
Section 116 of the No Surprises Act requires providers to set up a verification process to ensure directories are accurate. While no final regulations have appeared, CMS has issued guidance calling on insurers to implement the provisions.
Aetna is following that guidance, according to a spokesperson for the Hartford, Connecticut-based insurer.
“We are committed to maintaining accurate and complete provider directories,” the spokesperson wrote in an emailed statement. “Our efforts continue to evolve based on changing consumer needs, consumer and provider feedback, and in response to state and federal requirements.”
Efforts to reach other insurers named in the new study were not successful.
The evidence of inaccuracies leading to surprise bills is largely anecdotal, Butala said. However, at least one study shows a link. In 2020, researchers examined patients using provider directories to find mental health services, which the study noted are more likely to be delivered out-of-network to begin with. More than half the patients, or 53%, encountered inaccuracies and those patients were four times more likely to receive a surprise out-of-network bill, according to the research, published in Health Affairs.
Butala, who does consulting work for HiLabs but pursued the research in his academic capacity, described it as an “information transfer” problem that technology could solve, perhaps through some sort of standardization.
In fact, the Centers for Medicare & Medicaid Services has been exploring the idea since last fall through a request for information on a potential national directory of healthcare providers and services. The issue was recently addressed at an insurance industry conference, which showed that there is both skepticism and support for a national provider directory.
According to CMS, which cited figures from the Council on Affordable Quality Healthcare, a single national directory could save $1.1 billion a year in provider costs.
Photo: Arqam Nasir, Getty Images