Why Provider Directories Go Out Of Date

Health plan directories list which providers participate in a network, and they are frequently inaccurate. The inaccuracy is structural, driven by how participation information is created and transmitted.

The data has several owners

Participation is established by a contract between the insurer and a provider or provider group. The directory is a separate system that reflects that contract only after someone updates it.

Practice details such as address, accepting-new-patients status and hospital affiliation are maintained by the practice, not the insurer, and are typically reported on a schedule.

Large groups add another layer, because an individual clinician may join or leave a group without any change to the group's own contract status.

Contract changes are not instantaneous

When a contract terminates, there is usually a notice period, then an effective date, then a directory update. Each step introduces lag between reality and the listing.

Disputed renewals complicate this further. A contract may be scheduled to end and then be renewed at the last moment, during which time the directory may show either state.

Plans generally maintain continuity provisions for members in active courses of treatment when a provider leaves, and those provisions are described in the plan documents.

Facility and clinician status differ

A hospital can be in network while individual clinicians practicing there are not, because facilities and physicians hold separate contracts with the insurer.

Anesthesiology, radiology, pathology and emergency medicine are frequently provided by contracted groups whose network status is unrelated to the hospital's own status.

Federal protections now address several of these situations, but the underlying contracting structure that creates them has not changed.

Why verification has to be layered

Checking the directory establishes what the plan believes. Calling the practice establishes what the practice believes. The two are checked against each other because either can be stale.

Asking specifically whether the provider participates in the exact plan, not merely with the insurer, matters, because insurers operate multiple networks with different participation.

Recording the date, the name of the person spoken to and any reference number gives a member something concrete if a dispute follows.

What regulators require

Directory accuracy is a supervised area, with federal requirements for certain plan types and state requirements that vary considerably in scope and enforcement.

Some jurisdictions require plans to hold members harmless where a directory error caused out-of-network treatment, subject to conditions that differ by state.

Because the requirements vary by state and change over time, the state insurance department is the right place to confirm what protection applies to a particular plan.