Beyond the Disconnected Links: High Bets for Providers Directory Accuracy in the Times

Inaccurate provider catalogs have long been frustration for patients, providers and payers. Today, in the regulatory environment shaped by the Not Surprise Act (NSA), they have become entirely other things: legal and financial responsibility.

The NSA came into effect in 2022 to protect patients from surprise bills when they receive care from off-network providers. One of its key regulations requires that the health plan maintain an accurate provider directory and be updated at least every 90 days. The law also provides that the payer removes unproven providers and reflects changes within two working days.

But nearly three years of implementation evidence suggests that health plans are working to meet these requirements – and the cost of falling is huge.

Continuous inaccuracy and patient risk

Recent data highlights the root cause of the problem. A 2024 Secret Shopper Study published in the American Journal of Hosted Care (AJMC) reconnected the list of 1,802 providers, which was previously marked as inaccurate on five carriers in Pennsylvania. After more than 500 days, 40% of these lists are still incorrect, and only 13% have been completely corrected.

This coincides with the findings of a study published by JAMA, which used AI to analyze the provider catalog of five national insurance companies. The study found that 81% of doctors had inconsistencies on the list, mainly around address and professional names.

What is inaccurate is not just eroding trust – they directly lead to billing events, missed appointments, delays in care and in some cases performing actions.

Disputes are rising, and costs are also

The independent dispute resolution (IDR) procedure of the law is designed to mediate payment conflicts between payers and providers when differences are made. But the number of these disputes has surged.

According to a 2023 CMS report, more than 650,000 IDR cases were filed within one year, far exceeding expectations. In most of these disputes, providers have the upper hand, not only sending out the quantity, but also imbalance in the results.

For payers, this translates into growing administrative workloads, legal exposures and financial outflows, all of which are the reasons for the problem that should be addressed on paper: catalog accuracy.

Why is it broken?

The reason is both structural and operational. Directory accuracy is based on the regular, complete and proven updates of thousands of providers depending on the accuracy of the directory, and the process is largely a manual, inconsistent and distributed across systems.

The main challenges include the following.

• Multiple insurance companies per provider: Doctors usually need to update multiple payers when changes occur, each payer has different update requirements. This is often a manual and tedious process that requires calling, emailing and sending letters.
• Group Practice Data Report: Physicians often appear in practice, leading to challenges in group practice. Provider groups may not be able to accurately update the location or service information of a new provider, sometimes overlooking to update the new location or delete providers leaving the practice.
• Lack of provider data exchange standardization: There is no common format or data sharing mechanism between the plan and the provider, resulting in the creation of multiple files being exchanged and causing errors when entering and updating information. .
• Verification and provider data update lag: Internal processes can take weeks and in some cases reflect changes submitted by providers.

The result is a system that persists – not due to negligence, but due to complexity.

No reinforced supervision?

Although the NSA outlines clear requirements – a 90-day verification cycle, a 48-hour update window and accuracy assurance – the enforcement mechanism is not yet clear. Carriers are expected to comply, but there is no standardized fine or audit, and many are lagging behind.

The proposed national provider catalog (currently under review) by CMS is a step towards systemic reform. However, before it arrives, the payer will manage accuracy through his own workflow and the patient continues to suffer the consequences.

Build more sustainable solutions

Experts across the healthcare system agree that the current model is not sustainable.

Technological advances provide a potential path forward. Industry analysts point to the rise of provider data management platforms that utilize automation, real-time verification and centralized credential synchronization to maintain cleaner and more accurate directories.

These systems provide:

• A way that providers can use their data and easily update it through a self-service electronic portal.
• Leverage a more intuitive PDM system and provide automatic verification of address, professional and license data
• Centralized dashboards and data sources give payers the ability to audit directories better.
• Real-time API integration with credential databases such as NPPE, CAQH, and PECO, which attract the latest data and prevent manual errors and duplications

While these platforms are not the norm, they represent an emerging best practice and a critical step in reducing disputes, protecting members and achieving compliance.

in conclusion

The Unsurprising Act is a landmark that puts patients first. But its success depends on execution – the exact provider directory is core.

Today, the burden lies with the payer. Whether they rely on traditional workflows or invest in more scalable solutions that determine not only compliance but also care access, provider trust, and financial outcomes.

The question is no longer whether directory accuracy is important. That's how the health plan will solve it.

Photo: Pig, Getty Images

This article passed Mixed Influencer program. Anyone can post a view on MedCity News' healthcare business and innovation through MedCity Remacence. Click here to learn how.