For many, a necessary but often frustrating step in accessing health care services is determining whether a provider is in their health plan network.
The federal No Surprises Act, which went into effect in January 2022, established new rules to help protect consumers from surprise medical bills and remove them from payment disputes between a provider or health care facility and their health plan. It also included requirements for insurers to maintain, verify and update physician directories.
However, results from a recent data analysis of almost 450,000 physicians in the Medicare Provider Enrollment, Chain, and Ownership system found that only 19.4% had consistent address and specialty information across all the directories in which they were listed. The findings were published in a research letter.
“For patients, what this can mean is that if you go to your insurance provider’s directory and search for a physician, there’s a good chance that information may be incorrect,” explains Neel Butala, MD, MBA, an assistant professor of cardiology in the University of Colorado School of Medicine who led the data analysis. “The No Surprises Act does a lot to protect consumers, but if the requirement for accurate information isn’t being enforced, then patients still could encounter a lot of roadblocks to accessing care.”
Analyzing big data
Butala and his co-researchers searched all physicians in the Medicare Provider Enrollment, Chain, and Ownership System database in online physician directories of UnitedHealth, Elevance, Cigna, Aetna, and Humana, based on physician name and zip code in September 2022.
Among physicians found in more than one directory, they compared the consistency of practice street address across directories. They used the National Uniform Claim Committee taxonomy to assess the consistency of specialty designation across directories. A physician’s information was considered consistent if it was the same across all directories in which the physician was found.
The researchers partnered with HiLabs to aggregate and streamline this publicly available data, which they analyzed using the programming language Python. In doing so, they found that just 27.9% of physicians had consistent practice location addresses, whereas 67.8% of physicians had consistent specialty information.
Further, Butala and his co-researchers found that the consistency of information decreased as the number of directories in which the physician was listed increased. For physicians who had only one practice location listed, consistency in address across national insurance directories improved to 84.8%.
Finding solutions to an information problem
“A lot of these errors stem from having multiple addresses,” Butala explains. “For example, I recently moved from Boston to Denver, but I’m still in directories everywhere in Boston, what are known as ‘ghost’ entries.
“Providers are already so burdened with administrative work, so especially for the ones who practice in larger groups, staff may be inputting provider information as a batch process – listing every provider at every location, regardless of whether an individual provider practices at a specific location.”
What this means for health care consumers is frustration, Butala says – time spent on the internet or the phone to try learning not only whether a provider is in their network, but where they actually practice. While the recently published data analysis didn’t include consistency of phone numbers, there is potential to study that data across insurance directories, as well as information about whether a physician is accepting new patients.
“In an ideal world, and what Medicare has proposed, is the federal government creating a national provider directory with a unifying way of validating information and a standardized method for transmitting it,” Butala says. “I would love for that to happen, but in practice it would probably take many years to implement.”
The situation is further complicated, he says, because each insurer asks for different information from a provider or provider group, so a financial commitment from provider groups or health care institutions to hire and train additional administrative staff to update directories would be substantial.
“More short-term solutions might include the use of advanced analytics,” Butala says. “Machine learning techniques are perfectly suited to cross-check information from different sources and solve what is fundamentally a system-wide information transfer problem.
“I don’t think this problem has been given enough attention because it’s a tedious problem, a data quality problem. But it can easily exacerbate existing health care disparities. For someone who’s maybe not as tech-savvy or as familiar with the health care system, or who can’t take half a day away from work to figure out their coverage and make an appointment, they ultimately may not be able to access the care they need.”