Consistency of Physician Data Across Health Insurer Directories

Abstract

This study assesses the consistency of information across publicly available physician directories from 5 large national health insurers.

The No Surprises Act established new federal protections against surprise medical bills for out-of-network care beginning January 2022. Determining whether a physician is out of network hinges on accuracy of health insurer physician directories. Embedded in the No Surprises Act are numerous requirements for insurers to maintain, verify, and update physician directories.

Prior studies of health insurer physician directories have found significant inaccuracies, ranging from 5% to 93% of all listings, depending on the plan examined.^1,2,3 However, to our knowledge, no such studies have been conducted since implementation of the No Surprises Act or have looked at a national physician sample. We assessed the consistency of physician information across publicly available directories from 5 large national health insurers.

Methods

We searched all physicians in the Medicare Provider Enrollment, Chain, and Ownership System database in online physician directories of UnitedHealth, Elevance, Cigna, Aetna, and Humana, based on physician name and zip code in September 2022. Among physicians found in more than 1 directory, we compared consistency of practice street addresses across directories using an approximate matching algorithm based on similarity of address subsegments validated through iterative manual review (200 entries) and by contacting a sample of entries directly (600 entries) (correct classification in 99%). We did not penalize for differences in abbreviations or punctuation or evaluate secondary unit identifiers, such as suite number. We assessed consistency of physician specialty across directories at the classification level according to the National Uniform Claim Committee taxonomy to account for differences in presence of specialty vs subspecialty across insurers.⁴

A physician’s information was considered consistent if it was the same among all locations or specialties across all directories in which the physician was found. A physician’s information was considered inconsistent if physician address or specialty differed across directories or if a physician was found in a directory but an address or specialty present in other directories was missing from that directory. Additionally, we conducted a sensitivity analysis evaluating physicians who were only listed as practicing at a single location across all directories to isolate inconsistencies due to differences between addresses vs missing addresses across insurers. All analyses were conducted using Python version 3.4 (Python Software Foundation).

Results

Of 634 914 unique physicians in the Provider Enrollment, Chain, and Ownership System database, 449 282 were found in more than 1 directory. Among these, 19.4% had consistent address and specialty information across all directories in which they were found (Table). Among physicians, 27.9% had consistent practice location addresses and 67.8% had consistent specialty information. Consistency of information decreased as physician data were ascertained from more insurers.

Table. Consistency of Physician Address and Specialty Information Across 5 National Health Insurer Physician Directories.

	Among all physicians				Among physicians practicing in 1 location only
	Consistent	Inconsistent	Total	% Correct	Consistent	Inconsistent	Total	% Correct
Consistency of address and specialty
Total No.	86 349	358 158	444 507	19.4	69 312	48 884	118 196	58.6
Present in 2 directories	28 656	71 695	100 351	28.6	23 028	14 369	37 397	61.6
Present in 3 directories	34 543	132 695	167 238	20.7	28 392	19 860	48 252	58.8
Present in 4 directories	21 055	129 024	150 079	14.0	16 502	13 204	29 706	55.6
Present in 5 directories	2095	24 744	26 839	7.8	1390	1451	2841	48.9
Consistency of address
Total No.	125 350	323 932	449 282	27.9	100 994	18 102	119 096	84.8
Present in 2 directories	37 297	63 891	101 188	36.9	30 165	7486	37 651	80.1
Present in 3 directories	50 726	118 258	168 984	30.0	41 902	6697	48 599	86.2
Present in 4 directories	33 791	118 074	151 865	22.3	26 602	3378	29 980	88.7
Present in 5 directories	3536	23 709	27 245	13.0	2325	541	2866	81.1
Consistency of specialty
Total No.	303 999	144 567	448 566	67.8	81 551	37 320	118 871	68.6
Present in 2 directories	77 032	25 003	102 035	75.5	28 542	9201	37 743	75.6
Present in 3 directories	114 761	54 348	169 109	67.9	32 805	15 743	48 548	67.6
Present in 4 directories	96 447	54 118	150 565	64.1	18 516	11 223	29 739	62.3
Present in 5 directories	15 759	11 098	26 857	58.7	1688	1153	2841	59.4

In the subset of physicians who had only 1 practice location listed, consistency across directories was 58.6% for address and specialty information, 84.8% for practice address, and 68.6% for specialty information.

Discussion

In examining directory entries for more than 40% of US physicians, inconsistencies were found in 81% of entries across 5 large national health insurers. These results were driven by inconsistencies in addresses among physicians listed as practicing at multiple locations, which is concordant with prior research suggesting that most address errors stem from group practices reporting all physicians at all practice locations to insurers, irrespective of each individual physician’s practice locations.¹ Limitations include that some inconsistencies may represent true differences across insurers; however, the rare frequency of such occurrences is unlikely to affect the magnitude of the inconsistencies found in this study.

Beyond surprise billing, inaccurate physician directories can lead to delays in care due to difficulty finding the correct physician, challenges in regulators assessing health insurer network adequacy, and misrepresentation of network depth and breadth as consumers select health plans.

The challenges for insurers to build and maintain accurate physician directories stem from frequent changes and lack of a uniform standard. Additionally, the administrative burden for physician practices to send directory updates to insurers via disparate technologies, schedules, and formats costs practices a collective $2.76 billion annually.⁵ This study’s findings highlight the need for unified technology-enabled solutions, such as that proposed by the Centers for Medicare & Medicaid Services, which is seeking to create a single, centralized physician directory using modern interoperable formats.⁶

Section Editors: Jody W. Zylke, MD, Deputy Editor; Kristin Walter, MD, Senior Editor.

Supplement.

Data Sharing Statement