National Provider Directory to Launch Beta Test

- The problem of inaccurate "ghost networks" in provider directories has been a long-standing issue, with a 2018 CMS review of Medicare Advantage directories finding that over 48% of provider locations listed had at least one inaccuracy. These inaccuracies included incorrect phone numbers, providers not being at the listed location, or not accepting new patients when the directory claimed they were. - This initiative builds on the Interoperability and Patient Access final rule of 2020, which mandated that CMS-regulated payers make provider directory information publicly available through a FHIR-based API. The goal was to empower patients with their health information and break down data silos between payers, providers, and patients. - Inaccurate directories can lead to significant care delays, unexpected out-of-pocket costs for patients, and an erosion of trust in both insurance plans and providers. One study found that patients who encountered directory inaccuracies were four times more likely to receive a surprise outpatient out-of-network bill. - Maintaining directory accuracy is a significant challenge due to frequent provider changes, a lack of standardized data formats, and the manual, error-prone processes many organizations still use. The healthcare industry spends nearly $3 billion annually on maintaining provider directories, yet inaccuracies persist. - The No Surprises Act already requires health plans to verify and update their provider directory information at least every 90 days. However, a study in The American Journal of Managed Care revealed that 40% of inaccuracies persisted for an average of 540 days. - The move toward a centralized directory using standardized APIs aligns with the Health Level Seven (HL7) FHIR (Fast Healthcare Interoperability Resources) standard. This standard is designed to facilitate the exchange of healthcare information electronically and is a key component of the ONC's rules for interoperability. - Proposed legislation like the "REAL Health Providers Act" aims to increase accountability for directory accuracy in Medicare Advantage plans. If an enrollee sees an out-of-network provider listed in the directory, the plan would be responsible for ensuring the patient only pays in-network cost-sharing amounts. - A centralized directory is seen as a "single source of truth" that could reduce administrative burdens, particularly for providers who currently have to update their information across numerous health plan databases, each with different formats and requirements.