Accurate provider directories: Why payers can’t afford the risk

With the increase of Marketplace plans and enrollees, the transparency of ensuring health insurance shoppers have an accurate in-network provider list is a growing concern on a national and local level. As payers strategize how to offer more affordable care with exceptional quality, narrow network and limited network plans have emerged prompting federal and state officials to develop new standards in transparent provider lists.

The consequences of publishing inaccurate directories have become much higher in recent months. Because patients now have more options, presenting them with an unsatisfactory experience risks losing them to the competition. Penalties and fines from CMS can also have dramatic financial impacts. The bottom line is that health plans and TPAs simply cannot afford to get it wrong.


Recent events have underscored the importance of provider directories and their impact.


While CMS regulations have tightened national requirements for provider directories, new legislation in at least five states have gone farther in mandating that health plans update provider directories much more frequently and with more exacting accuracy standards. California, for example, passed State Senate Bill 137, requiring online provider directories to be updated weekly, with greater accuracy and with full product and contact information. As a result of this legislation, two of the nation’s largest health insurers recently incurred large fines and have been forced to pay over $38 million (and counting) in overpayment reimbursements to consumers for out-of-network care. A rash of class-action lawsuits have also followed.


Maintaining an accurate provider directory can be costly and labor-intensive, but it doesn’t have to be.


Building in-house architecture to automatically update your provider directories could be a costly, labor intensive, time-consuming endeavor that can often have mixed or unreliable results. And not having one at all puts you at significant risk and makes your business less competitive.


The best solution is one that is cloud-based, which reduces the need for initial and ongoing IT resources. It should also be self-maintaining and able to gather disparate data, populate it, and display it in the format you need with an update frequency that meets your line of business requirements. It should also enhance the member experience with intuitive functionality and a robust set of features that help members locate provider information and make informed provider selections.


Robust provider directory capabilities ensure legal compliance, mitigate the risk and costs of potential damages from noncompliance, and offer a superior user experience.



Chuck Rolfsen is the Chief Revenue Officer for Healthx. Through product design input and engagement strategy services, Healthx helps healthcare payers drive adoption and utilization of healthcare consumerism solutions including member portals and mobile apps.