Reporting provider directory information to health plans: Key issues and practice action steps

MGMA Stat - AugustĀ 15, 2019

Practice Efficiency

HIT Regulations

Robert M. Tennant MA
Provider directories are used by patients to find in-network physicians, to determine if physicians are accepting new patients, to find a health plan in which their current physician participates and to verify practice location and phone number. The challenge for the industry is to implement a process that effectively and accurately captures provider directory information for health plans without imposing significant burden on the reporting practices.
The Medical Group Management Association’s most recent MGMA Stat poll asked healthcare leaders to report their preferred way to submit their provider directory data to payers. The majority (75%) preferred an all-payer portal, 18% favored an individual payer portal and 7% were partial to “fax/mail.” Of those preferring all-payer portals, 37% stated that a private sector alliance would be best to manage that approach, 10% stated the government would be best, 8% believed a for-profit entity would be best and 45% responded that all would be acceptable.

This poll was conducted on Aug. 14, 2019, with 495 applicable responses.

Federal action

The issue of directory accuracy has now become a federal issue. The Centers for Medicare & Medicaid Services (CMS) has conducted reviews of the accuracy of Medicare Advantage (MA) online provider directories and determined that close to 50% of the information was inaccurate. As a result, CMS issued a new rule requiring insurers to provide up-to-date physician lists for MA and policies or potentially face fines of up to $25,000 per beneficiary for any violation.
With health plans now at risk for fines, directory requests will require immediate action on the part of practices. In some instances, plans may withhold reimbursement or remove non-responding physicians from their directories.

Practice reporting challenges

Typically, health plans reach out to practices with requests to update provider directory information via phone, mail, email or directing practices to log on to their proprietary web portal to update their information. With no standardized schedules and methods, practices are forced to reply to multiple requests for the same information, adding significant administrative burden for practices. This is compounded when there is no consistent (or accurate) practice contact point identified by their plans. The most common inaccuracies are:
  • The provider was not practicing at the location listed or not accepting patients at the location.
  • The phone number was incorrect or disconnected.
  • The provider was not accepting new patients when the directory indicated they were.
  • The provider was not accepting the health plan at the location.
Recently, there have been efforts to standardize the directory reporting process, with several industry groups seeking to consolidate practice reporting and reduce the number of health plan data requests.

Action steps for practices

For practices to maximize the utility of their health plan directories and to minimize the administrative burden associated with reporting provider information, practice leaders are encouraged to:
  1. Establish a contact person(s) within your organization to handle all health plan directory requests.
  2. Review (on a regular basis) the current accuracy of your provider data in the directories of your major health plans and update any inaccurate information.
  3. Encourage your health plans to partner with one or more of the industry solutions working to consolidate the reporting process.
Provider directories are a critical link between practices and their patients. Inaccurate information can impact access to care for patients and decrease the ability for practices to attract new patients. While efforts are underway to consolidate directory reporting, the process remains cumbersome and burdensome for practices. It is important that practices take the necessary steps to ensure that their directory reporting is timely and accurate.


Would you like to join our polling panel to voice your opinion on important practice management topics? MGMA Stat is a national poll that addresses practice management issues, the impact of new legislation and related topics. Participation is open to all healthcare leaders. Results of other polls and information on how to participate in MGMA Stat are available at:  

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About the Author

Robert M. Tennant
Robert M. Tennant MA
Director, Health Information Technology Policy MGMA Government Affairs


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