What’s the news: AMA President Jack Resneck Jr., MD, testified this month (PDF) before the Senate Finance Committee on the problem of so-called ghost networks of physicians and other health professionals, and also explored potential solutions to improve the accuracy of provider directories—especially as it relates to mental health care.
In addition to being a physician who has personally felt the impact of inaccurate directories, Dr. Resneck presented details of his JAMA Dermatology secret-shopper study published in 2014. He and his colleagues found that only 26.6% of the individual directory listings for dermatologists in a subset of Medicare Advantage plans were unique, accepting the patient’s insurance, and offering a medical dermatology appointment.
Dozens of other studies have shown similar results over the last decade, as did a study released on the morning of the hearing by the committee’s chair, Sen. Ron Wyden, D-Ore. In phone calls to a sample of 120 provider listings across 12 different health plans, 33% were inaccurate, had nonworking numbers, or had unreturned calls. Wyden’s study found that appointments were available only 18% of the time.
Why it’s important: “When directory information is incorrect, the results can be complicated, expensive and potentially devasting, especially to patients,” Dr. Resneck told the Senate Finance Committee.
“Inaccurate directories shift the responsibility onto patients to locate a plan’s network or pay for out-of-network care,” added Dr. Resneck, who chairs the University of California, San Francisco dermatology department. “Patients are financially impacted and may be prevented from receiving timely care. Moreover, in the long run, continuing to allow inaccuracies makes it easier for plans to fail to build networks that are adequate and responsive to enrollees’ needs. Accurate directories are a basic function and responsibility of health plans offering network products.”
The AMA also fielded a survey between 2017 and 2018 where 52% of physicians reported that their patients encountered coverage issues due to inaccurate information in provider directories at least once per month.
“Directory inaccuracy issues do not seem to be specific to any type of physician specialist or patient care, but in a moment where we are facing a mental health crisis, it is imperative that health plans offer adequate networks that are accurately reflected in their directories so that patients can access timely mental and behavioral health care,” Dr. Resneck’s statement says.
In the Wyden study, “more than 80% of the listed, in-network, mental health providers staff attempted to contact were ‘ghosts,’ as they were either unreachable, not accepting new patients, or not in -network.”
Dr. Resneck and other panelists at the hearing generally agreed that physician practices have an important role to play in directory accuracy but ultimately the responsibility lies with the health plans.
They also agreed on the need to standardize the process of data submission so that each practice is not dealing with 20 different submission processes for 20 different plans, especially as they deal with other administrative burdens such as prior authorization.
Dr. Resneck also stressed the need to require and enforce adherence to quantitative network adequacy standards, including wait-time requirements.
“In order to truly address the real harms, it is also critical that we address the network and access issues that directory inaccuracies may mask,” Dr. Resneck’s statement says. “For example, a bloated provider directory may be hiding a network that is wholly inadequate to serve the needs of the plan’s enrollees.”
Learn more: The AMA and the Council for Affordable Quality Healthcare Inc. produced a 2021 report, “Improving Health Plan Provider Directories: And the Need for Health Plan-Practice Alignment, Automation, and Streamlined Workflows” (PDF), examining the pain points for physicians and health plans in achieving directory accuracy.
The AMA also responded last year to a Centers for Medicare & Medicaid Services’ request for information on establishing a national directory of health professionals and services (PDF).
Find out more with the AMA about provider networks and access to care.
