Medicare Plan Directories: Sorry, Wrong Number

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By Mindy Yochelson

More than half of online directory listings relied on by Medicare managed care enrollees to find doctors in their health plan network are inaccurate.

The Medicare agency’s latest review found that 52.2 percent of the provider directory locations listed had at least one mistake: a provider not there, a wrong number, or a provider not accepting new patients in contrast to the listing.

“Many of the findings suggest the discrepancies will increase the member’s frustration” with the Medicare Advantage organization, the Centers for Medicare & Medicaid Services said in its second round of provider directory reviews. Frequent inaccuracies may also prevent sufficient access to care, the review, released Jan. 24, said.

The CMS examined online directories for the accuracy of the listings for 108 providers and their locations. The review—which did not name companies with problems—was conducted between September 2016 and August 2017.

The cardiologists, oncologists, ophthalmologists, and primary care physicians were examined in directories of 64 Medicare Advantage organizations.

The majority of the MAOs (37 out of 64) had between 30 percent and 60 percent inaccurate locations.

Accuracy Fell

The level of accuracy for this second review dropped from a somewhat smaller first round review involving 54 MA organizations, conducted six months before the second round. In that review, 45.1 percent of provider directory locations were inaccurate.

“Because MAO members rely on provider directories to locate an in-network provider, these inaccuracies could pose a significant access-to-care barrier,” the CMS said.

In the latest review, plans were hit with 54 compliance actions of various degrees.

An advocacy group for seniors praised the Medicare agency for taking actions against plans, but expressed concerns about a lingering problem. “On one hand, we’re encouraged that CMS is taking action,” David A. Lipschutz, senior policy attorney, Center for Medicare Advocacy, told Bloomberg Law Jan. 25. But on the other hand, “there are still widespread unacceptable errors in these directories.”

There should be stiffer penalties for noncompliance, Lipschutz said. In addition, “we would urge CMS to revisit the policy of requiring sponsors to hire independent auditors and include provider directory reviews as part of that audit,” he said.

CMS Directive

The CMS told the plans they should start performing self-audits and work with doctor group practices to ensure accuracy.

“The active participation and engagement of plan contracted providers is key to improving directory accuracy,” the review said. “A centralized approach would make data collection and verification more efficient and less burdensome for MAOs and providers and may result in more accurate and timely data sharing,” it said. However, it acknowledged that a centralized database would take time and there’s an immediate need to improve the directories.

Industry Response

Health insurers are working to address the problems in the directories, according to America’s Health Insurance Plans, a major industry group. AHIP and its members are committed to working with providers to identify short- and long-term solutions for improving accuracy rates, Cathryn Donaldson, AHIP’s director of communications, told Bloomberg Law Jan. 25. “Plans depend on doctors to submit accurate and up-to-date information,” she said. “Doctors depend on plans to reach out to them and educate them on keeping information updated.”

But the plans face challenges, she said. “For example, some physicians contract with multiple health plans, and there is no centralized or unified process for updating this information,” she said. A centralized database will take time to assemble, as the CMS pointed out, she said.

Another challenge is that group practices provide data at the group level rather than at the provider level. “A group practice often lists a provider at a location because the group has an office there, even if that specific provider rarely or never sees patients at that location,” she said.

A third review, involving 50 MA organizations, is in progress. The focus will include newly eligible MA organizations, a repeat of the current top 10 MA organizations, and organizations not reviewed during the first or second rounds, the CMS said.

To contact the reporter on this story: Mindy Yochelson in Washington at

To contact the editor responsible for this story: Kendra Casey Plank at

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