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Pennsylvania health plans are still having a hard time identifying and correcting online provider directory entries quickly, even though federal law requires them to update their directories every 90 days.
The Pennsylvania Department of Insurance says a "secret shopper" survey it commissioned found that about 62% of the 1,802 inaccurate entries the shoppers found in 2022 were still wrong when the shoppers reviewed the entries again, in late 2023 and early 2024.
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The shoppers also conducted a second survey wave in mid-2023. About 69% of the 5,170 erroneous entries found in mid-2023 wave were still wrong when the team looked at the entries for the re-checks that started in late 2023.
Those kinds of persistent inaccuracies in provider directories "can delay care, hinder scheduling or result in surprise out-of-network charges," the department said in a study publication announcement.
Pennsylvania study details: The Pennsylvania team looked at five health coverage providers and seven adult medical specialties for the first wave and eight coverage providers and 11 adult and pediatric specialties for the second wave.
The secret shoppers found the erroneous provider directory entries by combing through a large number of directory entries. At press time, an estimate of the total number of directory entries analyzed was not available.
Group vs. individual: All of the health coverage provider directories analyzed were supporting individual, family and small-group major medical plans sold through Pennsylvania's Affordable Care Act public exchange program.
But employers, benefits brokers, brokers consultants and technology vendors have been talking about provider directory accuracy problems in the ordinary commercial group insurance market and the self-insured plan market for years.
The U.S. Government Accountability Office (GAO) has pointed out that health plan provider directories are causing problems in the federal military and Coast Guard health plans, which cover active-duty employees getting care away from military or Coast Guard facilities as well as care for dependents.
GAO investigators recently noted in a report on the behavioral coverage provided by TRICARE, the health plan program for military personnel and dependents, that "patients experienced delays in care due to issues finding a civilian network provider using TRICARE's provider directory."
At one military facility, "in some cases, patients had to call over 20 different providers because the providers they contacted were no longer accepting TRICARE or were not accepting new patients," officials said.
Federal workers in New York state recently sued Elevance over faulty provider directories, and health plans in California recently had to fight hard to block a state provider directory bill that could have led to fines of $500 to $5,000 per 1,000 enrollees affected.
Federal policy implications: Provider directory quality is the kind of issue that could help Republicans and Democrats work together in the next Congress.
One focus could be the ability of the U.S. Department of Labor's Employee Benefits Security Administration to oversee the provider directories used by employers' self-insured health plans or create a provider directory information clearinghouse.
Officials at GAO, the congressional research center, have noted that EBSA has no general authority to enforce network adequacy requirements.
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Allison Bell
Allison Bell, a senior reporter at ThinkAdvisor and BenefitsPRO, previously was an associate editor at National Underwriter Life & Health. She has a bachelor's degree in economics from Washington University in St. Louis and a master's degree in journalism from the Medill School of Journalism at Northwestern University. She can be reached through X at @Think_Allison.
