Persistence of Provider Directory Inaccuracies After the No Surprises Act

ABSTRACT

Objectives: Provider directory inaccuracies have important implications for care navigation and access as well as ongoing regulatory efforts. We assessed the extent to which identified provider directory inaccuracies persisted across 7 specialties (cardiology, dermatology, endocrinology, gastroenterology, neurology, obstetrics-gynecology, primary care) and 5 carriers in the Pennsylvania Affordable Care Act insurance marketplace.

Study Design: A secret shopper survey recontacted inaccurately listed providers (N = 1802) between 403 and 574 days after they were identified in an earlier secret shopper survey.

Methods: Descriptive analyses, with tests of proportion and t tests to assess whether differences across carriers, specialties, and geographic locations were statistically significant.

Results: Of 1802 inaccurate provider listings, 451 (25.0%) had been removed at follow-up, 966 providers (53.6%) were successfully contacted, and 385 providers (21.4%) could not be reached. Of the recontacted providers, 240 (13.3%) were listed accurately at follow-up and 726 (40.3%) were listed with various inaccuracies, including 31.0% (n = 558) with inaccurate contact information, 11.2% (n = 201) listed under the wrong specialty, and 1.9% (n = 34) erroneously listed as being in network despite being out of network. We found substantial differences across carriers and specialties but not by rurality. Inaccuracies also were less likely to persist in the state’s 2 metropolitan areas. Among inaccurate provider listings, on average, 540 days (median, 544 days) had passed between the initial and subsequent contacts.

Conclusions: A large number of provider directory inaccuracies persist well beyond the 90-day expectation mandated by federal regulations, raising substantial concerns about compliance. These inaccuracies may impose substantial barriers to patient access and may render existing assessments of network adequacy ineffective.

Am J Manag Care. 2024;30(11):In Press

Takeaway Points

Despite the No Surprises Act requiring carriers to update and verify provider directories at least every 90 days and to develop a protocol for removing providers that cannot be verified, we found that provider directory inaccuracies often persist over long periods, with substantial differences in the duration of inaccuracies by carrier and metropolitan status.

• On average, inaccuracies persisted for 40.3% (n = 726) of searched providers for at least 540 days.
• At follow-up, 25.0% (n = 451) of searched providers had been removed from carrier directories.
• At follow-up, 13.3% (n = 240) of searched providers were listed correctly.

These findings raise questions about the challenges of regulatory compliance and about implications for patient access to care.

In managed care arrangements, which cover the vast majority of Americans today, consumers are highly incentivized to seek care solely from within their provider network.¹ To facilitate this, insurance carriers are mandated to publish consumer-facing online provider directories, which play a crucial role when consumers make choices about their health plan selections and particularly when they seek care. However, growing literature has identified substantial errors in provider directories ranging from incorrect contact information to inaccurate in-network designations across primary care,^2-5 behavioral health, and medical and surgical subspecialties.^6-9 Provider directory inaccuracies may contribute to delayed or forgone care and health inequities^8,10,11 and can challenge existing network adequacy regulations.^12-15

State and federal regulators have sought to remedy this situation by imposing requirements upon carriers to increase accuracy, although these vary widely in their scope and content.^16-18 For example, a majority of states impose requirements on carriers to regularly update their provider directories.¹⁹ However, it is unclear whether existing regulations have had noticeable effects given high rates of inaccuracies even in states with the most stringent regulatory standards, such as California.^6,7,20,21 At the federal level, the No Surprises Act (part of the Consolidated Appropriations Act of 2021), which went into effect in 2022, requires carriers to update and verify provider directories every 90 days at minimum and to develop a protocol for removing providers that cannot be verified.¹⁹ Although adequate enforcement has been identified as a substantial challenge, the effect of state and federal regulations on improving provider directory inaccuracies remains underexplored,^14,19 and questions have emerged about the extent to which provider directory inaccuracies persist despite these policies. To answer this question, we fielded a secret shopper survey among carriers in the Pennsylvania Affordable Care Act (ACA) insurance marketplace. Specifically, we resurveyed providers (N = 1802) from a broad set of specialties who were identified in a previous survey as inaccurately listed at least 403 days after the initial survey contact. We then determined whether the inaccuracies had been resolved (results not yet published).

METHODS

Data

The original secret shopper survey was conducted from June 13 to November 28, 2022. We surveyed 5 of the 7 carriers serving the Pennsylvania ACA marketplace in 2022 (omitting the integrated health systems of Geisinger and UPMC Health Plan). Callers were randomly assigned to call providers in 7 specialties (cardiology, dermatology, endocrinology, gastroenterology, neurology, obstetrics-gynecology, and primary care), identified from the carriers’ online directories. Callers searched providers in proximity to a “home address” assigned to them. These home addresses were randomly chosen from the entire state but distributed proportionally to enrollment in each ACA pricing region. Callers contacted providers at the number listed in the online provider directory and sought to find the next available appointment. During the calls, callers tried to verify the accuracy of the providers’ contact information, network status, and specialty. Because the callers presented as consumers, phone calls were terminated once any inaccuracy was identified. No actual appointments were scheduled. The original survey identified a total of 2134 providers with at least 1 inaccuracy in the following categories: (1) contact information (eg, provider not working at the number listed, phone line being disconnected); (2) network status (ie, being listed as being in network when they were in fact out of network), and (3) medical specialty.

To assess whether these provider directory inaccuracies persisted over time, we sought to recontact these 2134 previously identified providers from December 11, 2023, to January 8, 2024 (see eAppendix [available at ajmc.com]). This subsequent secret shopper survey occurred between 403 and 574 days (mean, 541 days; median, 545 days) after the initial survey contact. Callers were randomly assigned a provider from the original list of 2134 identified providers and then searched the carriers’ online directories for the assigned provider. If the providers were still listed, the caller attempted recontact (n = 1351). If the provider was removed (n = 451), callers moved on to the next randomly assigned provider. For the providers we were able to contact a second time, callers again tried to verify contact information, specialty, and network status. No actual appointments were scheduled. Overall, we were able to complete this process for 1802 randomly chosen providers from the list of 2134 original providers.

To assess differences based on the geographic location of providers, we relied on 2 measures. First, we utilized the list of rural zip codes provided by the Federal Office of Rural Health Policy to identify rural (n = 221) and nonrural (n = 1581) providers.²² Second, we also assessed differences based on ACA pricing regions. However, due to the limited number of observations, we combined the 2 metropolitan pricing regions of Pittsburgh (region 4) and Philadelphia (region 8) (n = 937) and compared them with the rest of the state (n = 865).

Analyses

We performed descriptive analyses, utilizing tests of proportion to assess differences between carriers and specialties in whether inaccurate provider listings had been removed from the directory, whether inaccuracies persisted on follow-up contact, and whether a provider was subsequently listed accurately at follow-up. We used tests of proportion to compare 3 categories of identified inaccuracies (contact information issues, inaccurate specialty listings, provider was out of network) and t tests to compare differences in the number of days between the 2 survey contacts. We also assessed whether differences existed for our outcomes of interest based on the rurality of the providers or whether they were located in the combined metropolitan ACA pricing region described earlier. Finally, we estimated linear probability models to derive adjusted results as robustness checks that confirmed our findings (see eAppendix).

RESULTS

Of the 1802 inaccurate provider listings identified in the first survey, 451 providers (25.0%) had been removed from carrier directories, 240 providers (13.3%) were listed correctly, and 726 providers (40.3%) continued to have inaccurate directory information (Figure 1). Inaccurate contact information was the most prevalent listing error (n = 558; 31.0% of searched providers), followed by inaccuracies related to medical specialty (n = 201; 11.2%). Inaccuracies related to network status were less common, occurring for 1.9% of providers (n = 34). Among providers with persistent inaccuracies (Figure 2), the mean number of days between the 2 survey contacts was 539.8 days (median, 544 days). We were not able to reach and verify information for the remaining 385 providers (21.4%). Detailed information for all analyses is presented in the eAppendix.

Differences Across Carriers

At the carrier level, we identified substantial differences in the removal rate of inaccurate provider listings (Figure 1), ranging from a low of 14.6% (n = 35; carrier B) to a high of 51.3% (n = 157; carrier C; P < .001 for difference). Inaccuracy rates ranged from 23.3% (n = 71; carrier C) to 52.4% (n = 130; carrier D; P < .001) of all searched providers. Inaccurate contact information ranged from 18.3% (n = 56; carrier C) to 42.7% (n = 106; carrier D; P < .001) of all searched providers, and inaccuracies related to medical specialty ranged from 5.2% (n = 16; carrier C) to 14.2% (n = 46; carrier A; P < .001). Inaccuracies related to network status ranged from 1.2% (n = 4; carrier A) to 3.2% (n = 8; carrier D; P < .099). With regard to persistent inaccuracies, we did not identify statistically significant differences in the number of days between survey contacts (Figure 2).

Differences Across Specialties

Differences across specialties, although consistently statistically significant, were less pronounced (Figure 1). Across the specialties, the rate of removal ranged from a low of 18.8% (n = 38) for endocrinologists to a high of 34.3% (n = 85) for obstetricians-gynecologists (P < .001) and inaccuracy rates ranged from 32.9% (n = 56) for dermatology to 43.5% (n = 178) for neurology (P < .019). Issues related to inaccurate contact information ranged from 25.3% (n = 43) for dermatologists to 34.2% (n = 140) for neurologists (P < .036). Inaccurate specialty information ranged from 7.6% (n = 13) for dermatologists to 16.3% (n = 50) for primary care providers (P < .008). Finally, network status inaccuracies ranged from 0.9% (n = 2) for cardiology to 3.5% (n = 6) for dermatology (P < .072). We did not find consistent statistically significant differences in the number of days between survey contacts (Figure 2) for providers with persistent inaccuracies across all specialties, with the exception of differences between cardiology (533.2 days) and gastroenterology (541.9 days; P < .016), neurology (541.8 days; P < .010), and primary care (541.0; P < .031).

Differences Across Geographies

We did not find statistically significant differences across the 7 outcomes presented above based on rural practice location. However, removal of inaccurate listings was more likely in the combined metropolitan areas compared with nonmetropolitan areas (28.5% vs 21.3%, respectively; P < .001). We also found overall inaccuracies to be lower in the metropolitan areas (36.1% vs 44.9%; P < .001). This also applied to contact information issues (27.5% vs 34.7%; P < .002) and inaccurate specialty designations (9.2% vs 13.3%; P < .004). However, we did not find any differences in the amount of time between survey contacts for providers with persistent inaccuracies based on rurality and ACA pricing region.

DISCUSSION

Our analyses showed that provider directory inaccuracies persist over extensive periods of time with 40% of searched providers continuing to exhibit inaccuracies after at least 540 days on average. Although 25% of listings had been removed, of those that remained, only 13% of previously identified inaccurate listings were fully corrected. These findings have important implications for current policy efforts to hold carriers accountable for the accuracy of their provider directories. In particular, because the No Surprises Act mandates corrective action for provider directory inaccuracies within 90 days of identification as well as consistent verification efforts, our results highlight the challenges of both implementing and enforcing these regulatory actions effectively.

High rates of provider directory inaccuracies have been identified in prior studies,^2,5,6,9,20 but we add to this literature not only by showing that the inaccuracies persist but also finding substantial variation at the carrier level. These findings indicate that carriers may take different approaches to network adequacy verification, with variation in staffing, resources, administrative capacity, and institutional knowledge that could affect the frequency and accuracy of these efforts. Our finding of geographic differences (eg, between the state’s metropolitan areas and nonmetropolitan areas) in inaccuracies and corrective action may be explained by carriers prioritizing updates in areas with more claims or enrollees. Because directory accuracy relies on the willingness or ability of providers to respond to heavy administrative demands involved with verifying, maintaining, and updating their information, it is plausible that providers in metropolitan areas are more likely to be part of larger health systems that are better equipped to respond to these administrative demands. Future research should seek to further investigate these underlying drivers related to the maintenance of accurate provider network information and to identify best practices.

Limitations

Our analysis has several limitations. First, data are limited to one state and to selected specialties. However, Pennsylvania is a relatively large state with diverse regional markets that mirror those in other geographic regions, with several of the carriers having multistate or national presence. We also purposively sampled a diverse set of specialties to enhance generalizability. Second, we were unable to assess the exact time points that directory accuracies were addressed between our 2 survey attempts. Third, as noted earlier, because callers presented as consumers, phone calls were terminated once any inaccuracy was identified. As a result, it is possible that we underestimated the extent of inaccuracies in the provider directories. Moreover, we were unable to verify information for 385 of the 1351 providers we sought to recontact (28.5%) because we were not able to connect to medical staff. In these cases, the providers were returned to the randomized calling list for repeated attempts to reach them. Finally, although we identified directory inaccuracies through our secret shopper approach, the frequency with which carriers themselves may be conducting similar assessments is unclear, although the No Surprises Act mandates carriers to verify and update provider directories at least every 90 days.

CONCLUSION

Our findings that 40% of searched providers continued to have inaccurate listings for at least 540 days on average suggest that current approaches by regulators and carriers are highly inadequate to meet the demands of consumers related to accurate provider directories. However, differences across carriers suggest opportunities for leveraging administrative and technological resources to improve provider directory accuracy and responsiveness. In the meantime, the extent to which directory inaccuracies persisted suggests that current regulatory approaches, including network adequacy and provider directory policies, may not prove effective,^14,19 particularly without accompanying enforcement mechanisms.

Author Affiliations: Department of Health Policy and Management, School of Public Health, Texas A&M University (SFH), College Station, TX; Division of General Internal Medicine and Geriatrics, School of Medicine, Oregon Health & Science University (JMZ), Portland, OR.

Source of Funding: This project was supported by CMS (within HHS) as part of a financial assistance award totaling $1,446,775, with 23% funded by CMS/HHS ($1,112,725 amount) and 77% funded by nongovernment sources. The contents are those of the authors and do not necessarily represent the official views of, nor an endorsement, by CMS/HHS or the US government. This work was also funded by the Insurance Department of the Commonwealth of Pennsylvania and the Robert Wood Johnson Foundation.

Author Disclosures: Dr Haeder reports serving as an expert witness and receiving grant funding from the Robert Wood Johnson Foundation on provider networks. Dr Zhu reports a position on the Cambia Health Physician Advisory Board (reviewing clinical coverage policies) and funding from the National Institutes of Health, Agency for Health Care Research and Quality, National Institute for Health Care Management Foundation, and American Psychological Association unrelated to this work.

Authorship Information: Concept and design (SFH); acquisition of data (SFH); analysis and interpretation of data (SFH, JMZ); drafting of the manuscript (SFH, JMZ); critical revision of the manuscript for important intellectual content (SFH, JMZ); statistical analysis (SFH); provision of patients or study materials (SFH); obtaining funding (SFH); administrative, technical, or logistic support (SFH, JMZ); and supervision (SFH).

Address Correspondence to: Simon F. Haeder, PhD, MPA, Department of Health Policy and Management, School of Public Health, Texas A&M University, 212 Adriance Lab Rd, 1266 TAMU, College Station, TX 77843-1266. Email: sfhaeder@tamu.edu.

REFERENCES

1. Employer Health Benefits 2022 Annual Survey. Kaiser Family Foundation. October 2022. Accessed April 2, 2024. https://files.kff.org/attachment/Report-Employer-Health-Benefits-2022-Annual-Survey.pdf

2. Haeder SF, Weimer DL, Mukamel DB. Secret shoppers find access to providers and network accuracy lacking for those in marketplace and commercial plans. Health Aff (Millwood). 2016;35(7):1160-1166. doi:10.1377/hlthaff.2015.1554

3. Tipirneni R, Rhodes KV, Hayward RA, et al. Primary care appointment availability and nonphysician providers one year after Medicaid expansion. Am J Manag Care. 2016;22(6):427-431.

4. Melnikow J, Evans E, Xing G, et al. Primary care access to new patient appointments for California Medicaid enrollees: a simulated patient study. Ann Fam Med. 2020;18(3):210-217. doi:10.1370/afm.2502

5. Burman A, Haeder SF. Directory accuracy and timely access in Maryland’s Medicaid managed care program. J Health Care Poor Underserved. 2022;33(2):597-611. doi:10.1353/hpu.2022.0050

6. Burman A, Haeder SF. Potemkin protections: assessing provider directory accuracy and timely access for four specialties in California. J Health Polit Policy Law. 2022;47(3):319-349. doi:10.1215/03616878-9626866

7. Elton TI IV, Xu WY, Haeder SF. Provider directory inaccuracy and timely access to physical therapy. World Med Health Policy. 2024;16(3):447-459. doi:10.1002/wmh3.607

8. Blumenberg E, Agrawal AW. Getting around when you’re just getting by: transportation survival strategies of the poor. J Poverty. 2014;18(4):355-378. doi:10.1080/10875549.2014.951905

9. Zhu JM, Charlesworth CJ, Polsky D, McConnell KJ. Phantom networks: discrepancies between reported and realized mental health care access in Oregon Medicaid. Health Aff (Millwood). 2022;41(7):1013-1022. doi:10.1377/hlthaff.2022.00052

10. Brown EJ, Polsky D, Barbu CM, Seymour JW, Grande D. Racial disparities in geographic access to primary care in Philadelphia. Health Aff (Millwood). 2016;35(8):1374-1381. doi:10.1377/hlthaff.2015.1612

11. Haeder SF, Xu WY. Consumer experiences navigating health care provider directories and support of federal policy action. World Med Health Policy. Published online June 19, 2024. doi:10.1002/wmh3.625

12. Haeder SF, Weimer DL, Mukamel DB. A knotty problem: consumer access and the regulation of provider networks. J Health Polit Policy Law. 2019;44(6):937-954. doi:10.1215/03616878-7785835

13. Haeder SF, Weimer DL, Mukamel DB. A consumer-centric approach to network adequacy: access to four specialties in California’s marketplace. Health Aff (Millwood). 2019;38(11):1918-1926. doi:10.1377/hlthaff.2019.00116

14. Burman A, Haeder SF. Without a dedicated enforcement mechanism, new federal protections are unlikely to improve provider directory accuracy. Health Affairs Forefront. November 5, 2021. doi:10.1377/forefront.20211102.706419

15. Haeder SF, Xu WY. When is a network adequate? consumer perspectives on network adequacy definitions. Am J Manag Care. 2024;30(9):424-432. doi:10.37765/ajmc.2024.89601

16. Busch SH, Kyanko KA. Incorrect provider directories associated with out-of-network mental health care and outpatient surprise bills. Health Aff (Millwood). 2020;39(6):975-983. doi:10.1377/hlthaff.2019.01501

17. Giovannelli J, Lucia K, Corlette S. Regulation of health plan provider networks. Health Affairs. July 28, 2016. doi:10.1377/hpb20160728.898461

18. Wishner JB, Marks J. Ensuring compliance with network adequacy standards: lessons from four states. Urban Institute. March 2017. Accessed April 3, 2024. https://www.urban.org/sites/default/files/publication/88946/2001184-ensuring-compliance-with-network-adequacy-standards-lessons-from-four-states_0.pdf

19. Haeder SF, Xu WY, Elton T IV, Pitcher A. State efforts to regulate provider networks and directories: lessons for the future. J Health Polit Policy Law. 2023;48(6):951-968. doi:10.1215/03616878-10852610

20. Burman A, Haeder SF, Xu WY. Provider directory inaccuracy and timely access for mental health care. Am J Manag Care. 2023;29(2):96-102. doi:10.37765/ajmc.2023.89318

21. Burman A, Haeder SF. Provider directory accuracy and timely access to mammograms in California. Women Health. 2022;62(5):421-429. doi:10.1080/03630242.2022.2083284

22. Eligible zip codes. Health Resources and Services Administration. Accessed March 22, 2024. https://www.hrsa.gov/sites/default/files/hrsa/rural-health/about/forhp-eligible-zips.xlsx