Results from a recent provider directory initiative conducted by America’s Health Insurance Plans (AHIP) provide new evidence of the difficulties plans face when attempting to update and verify provider directory information. The report, among other things, illustrates that it can take multiple outreach attempts to generate a validation response from providers and observed a general lack of provider awareness about the need for, and purpose of, responding to such attempts. The accuracy of provider information available to seniors has become a focus area for CMS, which earlier this year released the results of its own provider directory pilot and may soon be penalizing Medicare Advantage plans for not complying with federal requirements.

Michael Adelberg, principal at FaegreBD Consulting and a former top CMS MA official who had a leading role on network-adequacy issues there, says the findings are telling. “The big takeaway from the report is the documentation of how hard health plans, and their agents, work to get providers to update directory information,” he tells AIS Health. “Health plans are still on the hook for improving directory accuracy, but this report shows why this is a difficult task.”

AHIP conducted the pilot project in three states with 13 member plans and two vendors — Availity for the Florida pilot and BetterDoctor for the California and Indiana pilots — that contacted more than 160,000 providers between April and September 2016. The pilot was intended to not only improve the accuracy of directory information available from MA and other plans, but to test various approaches to “identify the most effective path to a potential solution at a national level.”

There is currently no standard process for updating directory information, although CMS officials in the past have expressed interest in developing a nationwide MA provider-network database. But CMS in its 2017 Advance Notice and Call Letter for MA and Part D plans dropped any language from the draft notice about a “national provider directory” and instead expressed its support for plans’ use of new technologies, including those that capitalize on machine-readable information, in simplifying their process of updating provider directories. And while nothing on the topic showed up in the most recent draft Call Letter, Adelberg suggests it is “something MA plans should keep on their radar screen.”

Federal standards related to provider directories vary for MA, health insurance exchange and Medicaid plans, but the responsibility ultimately lies with the plans. For example, plans offered through the exchanges must post directory information in machine readable format for the purpose of provider searches and update that information every 30 days, and Medicaid plans will have to use machine readable directories in 2018 as per last year’s major managed care regulation. MA plans, meanwhile, are required to proactively communicate with contracted providers on a quarterly basis to ensure that directory information is accurate and update any identified errors within 30 days of receipt.

CMS intensified its oversight of provider directory accuracy with a pilot launched last year by the Medicare Drug & Health Plan Contract Administration Group (MCAG). The first round of reviews showed that, for example, 45.1% of provider locations listed in the online directories reviewed were inaccurate (MAN 1/26/17, p. 1). And of the 54 MA organizations whose online provider directories were monitored, 21 received letters warning that if they failed to correct the deficiencies identified, they could be subject to enforcement actions. The CMS project is now in its second round of reviews, with 64 MAOs subject to monitoring. When asked whether any fines have yet been imposed on plans, CMS spokesperson Raymond Thorn responded that CMS continues to work with MA organizations in correcting their directory deficiencies.

The AHIP members that participated in the pilot are: Anthem, Inc., AvMed, Inc. Blue Shield of California, The CareMore Health Plan unit of Anthem, Cigna Corp., Florida Blue, the Health Net unit of Centene Corp. (California), Humana Inc., L.A. Care Health Plan, Molina Healthcare, Inc., SCAN Health Plan, WellCare Health Plans, Inc. and Western Health Advantage.

The vendors’ efforts to update and/or verify directory information included phone calls, emails and alerts within existing portals. Yet each vendor’s attempts resulted in less than one-fifth of providers contacted actually completing the validation process, according to the report. Only 18.4% of the providers contacted by BetterDoctor, for example, completed the validation process as it pertained to information required by California law (SB 137), although 47.5% completed the process for information required by MA (see table below). That difference, however, was likely due to the fact that the MA requirements are a subset of the state law, which also allows health plans to withhold payment to a non-responding provider for 30 days.

Purpose of Updates Is Unclear to Providers

Additional findings, which were evaluated by NORC at the University of Chicago, include:

  • Providers demonstrated a general lack of awareness regarding the need to proactively alert plans of changes and/or respond to requests from plans to validate or update information.

  • It often took multiple attempts to get providers to respond to validation requests. Statistics from Availity, for example, showed that it took an average of seven notifications to complete the validation process. And when providers did respond, they revised nearly two-thirds of the key data elements being reviewed.

  • Providers weren’t always aware of the federal and/or state regulations requiring plans to have accurate, up-to-date directory information or of their own accountability, despite having language in their contracts with plans requiring providers to submit directory updates in the event of a change.

  • Their requested mode of communication wasn’t always the most effective. For example, 48% of providers indicated to BetterDoctor that their preferred mode of communication was email, but phone calls resulted in the highest level of validation at 39.2%. Moreover, response rates improved when vendors provided urgent deadlines to respond.

The report identified three main areas in which there are opportunities to work on a “national solution.” These are: (1) improving provider engagement, with a focus on reducing provider burden in the process; (2) increasing provider accountability through, for example, enhancing and enforcing contractual requirements to verify/update information or, in states that allow it, delaying payment if a provider fails to respond to attempts to validate directory information; and (3) improving data coordination and integration, such as developing an industrywide set of standards for provider directory data definitions or other validation standards. AHIP concluded that health plans should consider adopting standard processes and channels for allowing providers and consumers to identify provider director discrepancies.

View the report at

Key Findings From the AHIP Provider Directory Initiative

Key Statistics: Availity

Estimated providers contacted for validation via Availity portal


Percentage of practices with a contact attempt


Percentage of practices successfully contacted


Percentage of providers who completed the validation process


Average number of notifications to complete the validation process


Average number of questions asked (for a one-provider, single-location practice)


Percentage of key data elements edited by providers when they submit data to the vendor


Key Statistics: BetterDoctor

Estimated providers contacted for validation via phone/fax


Percentage of practices with a contact attempt


Percentage of providers who completed the validation process*

18.4% (CA SB 137)

47.5% (MA)

Success of different modes of contact

18.1% (fax to online form)

39.2% (phone)

Average number of notifications to complete the validation process

1.4 – 2.3 contacts

Average amount of time required by provider to complete validation

16.35 minutes (online form)

4.22 minutes (phone)

Average number of questions asked (for a one-provider, single-location practice)

37 questions (online form)

24 questions (phone)

Percentage of key data elements edited by providers when they submit data to the vendor


*18.4% of providers completed validation related to information required by SB 137, a California state law that places several directory-related requirements on plans and permits them to delay payment if a provider fails to respond to attempts to confirm directory information. 47.5% completed validation for information required by Medicare Advantage.

SOURCE: America’s Health Insurance Plans, March 2017 Issue Brief, “Provider Directory Initiative Key Findings.” Visit