Accurate provider directories are essential to ensuring enrollees can access the care they need and deserve. Leading healthcare advocates echo this sentiment, which serves as the foundation for the proposed Requiring Enhanced and Accurate Lists of Health Providers Act (REAL Health Providers Act).
Inaccurate provider directories and the prevalence of “ghost networks” have posed serious accessibility challenges in healthcare, especially in mental health services. These issues have left many enrollees frustrated and often questioning whether they’re truly receiving the healthcare services they were promised. To address these gaps, lawmakers introduced the REAL Health Providers Act. This legislation aims to establish additional requirements for Medicare Advantage (MA) organization provider directories while holding stakeholders accountable for maintaining accurate and updated provider information. By tackling this critical issue, the proposal seeks to empower patients—particularly seniors—with the tools necessary to access the care they need and the care they’ve purchased.
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Tune into this podcast episode with Kate Deiters and Zach Snyder as they unpack the key points of the legislation and discuss what this means for Medicare Advantage Organizations in the future.
Current Medicare Advantage Provider Directory Requirements
Under the existing regulations, MA organizations must maintain clear, accurate, and standardized information about their provider network in their online and printed directories.1 The Centers for Medicare & Medicaid Services (CMS) requires MA organizations to provide plan directories to enrollees by October 15th each year, within 10 days of enrollment, and upon request by an enrollee throughout the year.
In addition, MA organizations are required to have printable and searchable provider directories on their websites. Furthermore, they must maintain a publicly accessible Application Programming Interface (API) that complies with industry standards, providing a comprehensive and accurate directory of the MA plan’s contracted provider network.
To keep the directories up-to-date, MA organizations must contact contracted providers quarterly to verify and update at a minimum the following directory information:
- Provider Name
- Provider Specialty
- Whether or Not the Provider Accepts New Patients
- Practice Address
- Phone Number
- Provider Offers Telehealth Services
- Provider Cultural and Linguistic Capabilities, Including Languages and American Sign Language
Directories must be updated within 30 calendar days after the MA organization receives verification or updates about provider directory information.
Proposed New Requirements Under the REAL Health Providers Act
The REAL Health Providers Act introduces additional requirements to address gaps in existing MA directory standards. Key elements of the legislation include the following.
Provider Directory Accuracy
1. Provider Directory Information
For plan year 2028, MA organizations providing network-based plans must maintain accurate, publicly accessible provider directories on their websites. The directories are required to include essential information for in-network providers to help patients access contracted providers and covered services. At minimum, MA organizations must validate and include the following directory information:- Provider Name
- Provider Specialty
- Provider Contact Information
- Primary Office or Facility Address
- Whether the Provider Is Accepting New Patients
- Accommodations for People with Disabilities
- Cultural And Linguistic Capabilities
- Telehealth Capabilities
2. Regular Data Validation and Updates
Provider directory information must be verified and, if needed, updated at least once every 90 days or more often. This approach aligns with the requirements of the No Surprises Act, emphasizing a continuous process of provider outreach and verification rather than limiting updates to a quarterly schedule.3. Indicate Providers Who Haven’t Verified Their Data in the Directory
Where a provider’s details cannot be validated within the stipulated timeframe, MA organizations are required to indicate in the directory that the provider’s information may not be current. The intention is to improve transparency for enrollees as they navigate provider networks or seek to schedule an appointment.4. Remove Non-Network Providers Within 5 Days
When the MA organization determines a provider is no longer participating in the network of such plan, they must remove that provider from the online and printed directory listings within five business days.5. Hospital and Facility Verification
While the REAL Health Providers Act requires provider information to be verified at least every 90 days, the Health and Human Services (HHS) Secretary may allow plans to verify hospital and other facility information less frequently, but in no case less frequently than once every 12 months.Accountability for Provider Directory Accuracy
Cost-Sharing for Services Furnished Based on Reliance on Incorrect Provider Directory Information
The legislation addresses situations where inaccurate directories lead enrollees to seek care from out-of-network providers. If an enrollee receives services from an out-of-network provider who, on the date on which the appointment is made, was listed as in-network in the plan’s directory, the MA organization must cover the out-of-network care, provided that the service is a covered item. Beneficiaries must also be informed of these protections both in their provider directories and through Explanation of Benefits (EOB) statements.
Annual Provider Directory Accuracy Analysis and Reports
MA organizations will need to conduct an annual analysis and report on the accuracy of their provider directory information for each MA plan they offer. The proposed legislation calls for a review of a random sample of providers listed in the directory, with a focus on specialties prone to inaccurate information, as determined by the Secretary of Health and Human Services (HHS). Examples cited of such specialties are mental health or substance use disorder treatment.
A report must then be submitted with the results of the accuracy analysis, along with an accuracy score of the directory using a verification method specified by the Secretary.
Publication of Provider Directory Accuracy Scores
Beginning with plan years beginning on or after January 1, 2029, the accuracy score for each plan’s provider directory must be prominently displayed in the plan’s provider directory.
Additionally, the HHS Secretary will make these scores available in a machine-readable format on CMS’s website.
What's Next? Legislative Status and Future Updates
The REAL Health Providers Act is currently under review, having been referred to the Committee on Ways and Means and the Committee on Energy and Commerce. We will keep you updated on any developments as it moves through the legislative process. Be sure to subscribe to our podcast and YouTube Channel for the latest updates.
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