Why the No Surprises Act falls short in improving provider directory accuracy

Regulation fails to address how patients utilize provider directories.

I consider myself a capable person with multiple years of experience working for one of the nation’s top healthcare payers, but even I can’t effectively use a payer’s online provider directory to find a doctor. I’m not alone. Consumer frustration surrounding payer provider directories drives low member satisfaction, poor ratings for payers and unnecessary payer administrative costs to resolve complaints. To protect consumers, regulators push to improve the consumer experience by holding payers accountable for the accuracy of their provider directories. However, a fundamental disconnect exists between regulators and consumers around the purpose of a payer directory. With today’s technology, consumers are more likely to use Google to find a doctor than they are to use their payer’s directory. Regulators need to better understand the consumer need before defining policies to ensure they will affect meaningful change.

Provider Directories: a low value burden

On December 27, 2020, the No Surprises Act was signed into law with a primary goal of eliminating surprise billing. Embedded in the No Surprises Act is a 90-day “verification” process which does little to solve the pervasive issues plaguing payer provider directory accuracy. While the final rule is still pending, the legislation requires payers to verify and update their provider directory at least once every 90-days with specific focus on the provider’s network participation status, name, address, specialty, telephone number and digital contact information.

Ideally, the payer provider directory would be used to support two use cases: confirming the provider’s network participation status and finding care. Like most of Americans, I rarely have reason to look up a provider I’m already receiving care from in a payer’s provider directory. I simply want to know that the insurance I previously used is still accepted or that my new insurance will be accepted by my existing provider. When I’m looking for care from a new provider, I need a bit more information. I want to know which providers are closest to me, which provide the type of care I’m looking for, which I can get an appointment with, and which are “better” than others. Regulators have biased directory requirements in favor of the “finding care” use case to help consumers. However, regulators fail to acknowledge that payers simply can’t compete with search engines like Google and continue to push legislation to solve the consumer experience problem, but payers will never be able to succeed in this space.

Regardless of which use case you consider, maintaining provider directories is an administrative burden for both payers and providers. While a directory is needed for payers looking to recruit membership based on their contracted network (our first use case) and help connect members seeking care to in-network providers (our second use case), directories aren’t high value products for the provider community. Despite consumers using directories to find care, providers believe it is not a high impact marketing tool for member recruitment and prefer to rely on word of mouth, search engine results, printed advertisements and tv ads. Without a vested interest from the provider community or penalties that can be attributed to providers non-compliance with maintaining their directory data, payers will continue to fail accuracy standards for directories. The 90-day verification timeline from the No Surprises Act falls short of holding providers accountable for maintaining the accuracy of their data because it does not impose any meaningful consequence for the provider who fails to do so. While the final rule on the legislation is still pending, historically CMS has done little to nothing to hold providers accountable for the data they’re providing to payers for directory use. In the past, CMS has looked to penalize payers for the lack of directory accuracy. The lack of impact this has had to consumers is evident as the need to improve directory accuracy continues to be a problem to solve.

Regulations mandate that payers publish accurate provider directories. But are they relevant? A Patient Search Behavior Survey in 2020 by Yext compiled results from 12 months of research and concluded that 71% of members initially use a search engine like Google, Bing or an equivalent to find care and only 21% initially use a payer provider directory. The Yext survey further establishes that once a member has selected a provider, 42% of members then use their payer website, likely trying to determine network participation status. I can relate to this. When I struggled to use my healthcare payer’s directory, I also turned to a Google search to get what I needed. There is an emergence in the healthcare IT space where organizations like WebMD and Healthgrades are developing technology to connect patients and physicians based on their specific healthcare need. Moreover, as regulators push from several directions to make data more accessible, these healthcare IT companies can enable features on their website to show which insurance plans each physician is accepting. As these healthcare IT companies and search engines build solutions to meet the consumer need, the payer’s provider directory becomes more and more irrelevant.

Accurate, complete provider: A search for the holy grail

A payer’s ability to succeed in the space of provider data accuracy is limited by multiple factors including conflicting regulations, system limitations and a lack of input from the provider community. While payers often find solutions to work through conflicting regulations and system limitations, they have a heavy dependency on providers for the data itself. Obtaining an accurate and complete data set from each provider is so challenging that many payers have moved to a “whatever we can get” mindset where they willingly accept the provider’s information in whatever state it can be provided in. The lack of updates and inconsistent formatting from provider’s exacerbate data entry errors impacting consumers.

Payers and providers alike talk of the benefits to a national central repository to reduce administrative burden and theoretically improve quality, yet without a mandate from regulators, it has never come to fruition on a national scale. California State Bill 137 tried centralizing and standardizing provider directory requirements, but 7 years after signing the law, no measurable improvement to the consumer experience has been achieved. While in theory, building a central repository for provider directory data has its merits, buy-in from the provider community and a commitment to regularly update their data is critical for success.

While one might think that provider directory data isn’t very volatile and hard to maintain, 2021 research by LexisNexis®Risk Solutions shows approximately 33,000 provider addresses, 1,750 phone numbers and 3,300 names change every week across all providers in the US. Even harder to track than addresses, phone numbers and names are the accepting new patient indicators which can change daily at the provider level, at the address level and at the network level (Medicare HMO, Commercial PPO, etc.). Knowing that this specific indicator is a key factor in displaying a provider in a payer’s directory due to regulations, its lack of maintenance can be quite impactful to the consumer’s experience. With this level of volatility in the data set, payers are constantly chasing a moving target and regretfully falling short.

One pervasive issue driving down the accuracy of provider directories stems from the provider community’s tendency to over attribute which physicians are at which locations to hedge their bets with claim payment activities. Getting paid by the insurer is the primary concern in the provider’s relationship with the payer. Because many claim payment systems require a pre-existing link between the physician and the service location, providers have learned that attributing every physician to each practice location drives the highest success rates for claim payment. This practice of over attribution also has the added benefit to providers who are looking to reduce the administrative burden of tracking which physicians are operating out of which locations and when. When payers use the same system for claim payment and provider directories, this results in displaying providers at locations incorrectly, driving down the consumer experience and impeding a payer’s ability to meet directory accuracy standards.

The consumer experience is top of mind across the industry, but regulators are off the mark with their “90-day verification” mandate in the No Surprises Act. They’ve created an additional administrative burden for both payers and providers that will likely see a high volume of non-compliance unless the final rule institutes heavy penalties for both payers and providers. Consumer frustration will remain high because the primary need to see if the provider they’ve chosen is accepting their insurance via the payer-provider directory remains a gap. Regulators should spend time understanding the trend of the industry to move to healthcare IT companies and search engines for finding care as the better solution. Furthermore, payers should support the healthcare IT companies and search engines with indicators to display the plan participation status of a provider building a one-stop shop quality experience for the consumer.

Lianne Eberle brings over 8 years of experience with payers from her previous role with Anthem, Inc. As a previous customer and key stakeholder to LexisNexis Risk Solutions, Lianne is uniquely positioned to lead the PDIS strategy and help us usher in some of the enhancements and new innovations we have prioritized for this suite of solutions.