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Life Health > Health Insurance > Medicare Planning

Stale Health Care Provider Directories Make Officials Sick

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What You Need to Know

  • CMS says about half of the entries in official health insurance company provider data files are incomplete.
  • One question: How can it encourage insurers it does not regulate to use a national provider data service?
  • Another question is whether a provider data hub should charge fees.

A federal agency says health insurers’ provider directory records are a mess.

The Centers for Medicare and Medicaid Services has proposed creating a health care provider directory service of its own.

Doctors and hospitals could send their information to a new National Directory of Healthcare Providers & Services, or NDH, and health insurers could use the NDH to keep their own provider directories up to date, without pestering providers for contact information and insurance plan participation updates, CMS officials say in a public request for information that’s set to appear in the Federal Register Friday.

What It Means

If the NDH project worked, it could reduce the odds that your clients will have to spend days trying to find health care providers who accept their insurance and are taking new patients. That could save some clients a fortune by protecting them against the need to see out-of-network providers who might saddle the clients with huge bills that the clients must pay out of their own pockets.

In the short run, the NDH project could cause headaches for the insurance company teams and vendors that now create and maintain their own health care provider directories.

The directory effort could also lead to new questions about the types of services and information should be available free of charge, and what kind of activities should be left in the hands of private, for-profit companies.

The U.S. Securities and Exchange Commission, for example. has helped investors but hurt securities filing access services by setting up the free online Edgar securities document database.

The Issue

Patients have long complained that many of the entries in health insurers’ provider directories are incorrect.

CMS — the federal agency that oversees Medicare, and administration of federal health insurance laws — says it checked insurers’ provider data files by comparing them with other sources of information, such as the National Plan and Provider Enumeration System and the U.S. Postal Service address verification database.

Over the period from 2017 through 2021, only 47% of the provider entries in insurers’ provider records contained a complete set of information, including accurate contact information, health plan affiliations and indications of whether the providers were accepting new patients.

CMS had trouble finding 27% of the providers in the data files with the providers in the directories’ on the health insurers’ websites.

That might be partly due to the static nature of machine-readable officials, CMS officials say.

But officials say they believe they could help by creating a centralized, affordable NDH data hub that all other provider directory data services, health insurers and other players could use.

Accessing Vendor Data

CMS acknowledges in the request for information that private data vendors are already trying to improve health plans’ provider directories.

Officials note that vendors charge for access to their data.

That “inherently creates barriers to use and inequity for healthcare entities that do not have the resources or funds to buy access to these privately-owned endpoint directories,” officials say.

“A free and publicly available CMS-sponsored NDH could minimize and may even eliminate this cost barrier associated with private industry created digital endpoint directories, and ensure all stakeholders have equal access to the relevant digital contact information they may need to securely exchange health data,” officials add.

Questions and Comments

CMS is asking members of the public for comments on the NDH project idea.

“Understanding that individuals often move between public and commercial health insurance coverage, what strategies could CMS pursue to ensure that an NDH is comprehensive both nationwide and market-wide?” officials ask. ”Are there specific strategies, technical solutions, or policies CMS could pursue to encourage participation in an NDH by group health plans and health insurance issuers offering group or individual health insurance coverage for programs or product lines not currently under CMS’ purview?”

Comments will be due after the official Federal Registration publication data.

CMS lists Alexandra Mugge and David Koppel as the project contact people.

(Image: Shutterstock)


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