On Nov. 13, 2015, the Centers for Medicare & Medicaid Services updated guidance in the 2016 Call Letter and Medicare Marketing Guidelines that previously called for health plans to update provider directories on a monthly basis. Unfortunately for patients, the data is now required to be updated on a quarterly basis – leaving patients with data that is up to three months old when they need health care.
These regulations were initially set because provider directories were found to be inaccurate – with many patients reporting unexpected out-of-network fees after their provider was incorrectly listed as in-network. It's why beginning Jan. 1, 2016, health plans will face fines of $25,000 per beneficiary for incorrect listings.
This update to the mandate is a step backward, and will cause future confusion and unnecessary financial burden for patients, providers and health plans. Inaccurate data will cause unnecessary phone calls and unpaid bills to providers and health plans, and will severely impact the patient.
Provider data is constantly changing, and phone numbers, addresses, whether or not the provider is accepting new patients, etc. are crucial elements that shape one's personal health care decisions. But most importantly, patients should feel confident that the providers listed on their health plan's site will, in fact, be covered by their insurance. Unfortunately with this new mandate, patients cannot be assured that this is the case.
While the provider data is vast and at times unruly, health plans and providers have access to technology and vendors that can help them manage the data in real-time, so they can focus on providing optimum care instead.
CMS should keep in mind that the initial mandate was set for health plans, through their relationships with the provider system, to update provider directory data on a monthly basis because it was in the best interest of the patients. Backtracking on this initial requirement sends the wrong signal.
In today's market, there is really no excuse for having inaccurate information in provider directories for months. Not only is it bad for patients, it's bad for the cost of health care as a whole. Seeing that efforts are currently underway to improve the system provides a good start that should give patients a sense of hope. However, we have the opportunity to fix the root problem by putting the right systems and processes in place now, rather than later.