by Jeanette Thornton and Matt Eyles
July 7, 2016
Health plans publish provider directories that include comprehensive listings of the physicians and other clinicians, facilities (e.g., hospitals), and pharmacies that participate in their networks. These directories, which are typically posted online and in a searchable format, are a valuable resource for individuals and their families.
Directories can help answer key questions before individuals and their families decide which health plan to enroll in or how to access care once enrolled. For example, is my primary care physician or specialist in the health plan’s network? Is the hospital closest to where I live in network? As a result, it’s essential that provider directories reflect the most current and accurate information about participating providers and facilities so that individuals can maximize the value of their coverage.
America’s health plans are committed to ensuring consumers and patients have complete and accurate information about available providers to make informed health care choices. However, our member plans’ experience demonstrates establishing accurate provider directories is a shared responsibility that requires a shared commitment from health plans and providers to ensure consumers and patients have the right information they need.
That’s why health care stakeholders worked closely with the federal government as it established requirements for what information must be included in provider directories, and in some cases like Medicare Advantage, require plans to contact on a quarterly basis the providers in their network.
While getting and keeping provider data up to date sounds simple in concept, there are some meaningful challenges to overcome. For example:
The challenges of getting and keeping the content up to date are further complicated by the fact that physicians contract with multiple health plans, and unfortunately, there’s currently no unified process for updating directories. With each health plan doing this on its own, this process is time consuming and costly. It’s even more so for medical practices and hospitals, when you consider that each medical practice must work separately with each Medicare Advantage plan, Medicaid health plan, and commercial health plan with which it contracts.
So early this year, AHIP has launched a pilot program to address these challenges. The pilot is taking place in three states with 12 AHIP member health plans and has three goals:
We expect pilot results to be available later this year and will work with consumers, providers, and others to identify best practices and develop solutions based on lessons learned. We recognize these activities are crucial to improving the consumer experience in health plans, which continue to provide high-quality health care to the individuals they serve.
Jeanette Thornton is SVP of Health Plan Operations & Strategy and Matt Eyles is EVP of Policy and Regulatory Affairs at AHIP.