Are enrollees receiving the healthcare services they were promised? Inaccurate provider directories and ghost networks have been longstanding concerns in the healthcare industry, particularly with mental health services. Recognizing the need for improvement, lawmakers have proposed new legislation to address inaccurate data and help seniors receive the care they purchased. The Requiring Enhanced and Accurate Lists of Health Providers Act, also known as the REAL Health Providers Act, aims to prevent ghost networks by imposing additional requirements on Medicare Advantage (MA) plans to maintain accurate provider directories.
Listen Now to Hear the Latest Update
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.
Medicare Advantage Provider Directory Accuracy Requirements
Under the existing law, 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.
💡 Tip: Download our policy brief to learn more about the current provider directory requirements.
Proposed Provisions of the REAL Health Providers Act
The REAL Health Providers Act proposes key changes to the existing rules governing MA plan provider directories.
Provider Verification and Directory Update Process
Starting in plan year 2027, network-based MA plans would be required to do the following:
1. More Frequent Outreach, Verification, and Updates: MA plans must verify provider directory information at least every 90 days. This aligns with the No Surprises Act and calls for a rolling provider outreach and verification strategy instead of quarterly updates.
2. Indication of Unverified Providers in the Directory: MA plans must clearly note in their directories which providers have unverified information and that the information of such providers may not be up-to-date.
3. Prompt Removal of Providers: When the MA plan determines a provider is no longer part of the network, they must remove that provider from the online and printed directory listings within five business days.
Provider Directory Information
Provider directories would be required to include all the information enrollees would need to access covered benefits from a contracted provider. MA organizations would need to verify: the provider name, the provider specialty, contact information, primary office or facility address, whether the provider is accepting new patients, accommodations for people with disabilities, cultural and linguistic capabilities, and telehealth capabilities.
Hospital and Facility Verification
While the REAL Health Providers Act requires provider information to be verified every 90 days, the Health and Human Services (HHS) Secretary may allow plans to verify hospital and other facility information less frequently, as long as annual verification is ensured.
Cost-Sharing for Services Furnished Based on Reliance on Incorrect Provider Directory Information
If an enrollee receives services from an out-of-network provider who was listed as in-network in the plan’s directory when the appointment was made, the MA organization would be required to cover the out-of-network care, as long as it was a covered item or service. The enrollee would only be responsible for in-network cost sharing.
Annual Provider Directory Accuracy Analysis and Reports
MA organizations might need to conduct an annual analysis and report on the accuracy of their provider directory information. They could use a random sample of providers listed in the directory, including those from specialties with high rates of inaccurate information as determined by the HHS Secretary. This might involve specialties like mental health or substance use disorder treatment. The report would need to include an accuracy score for the provider directory information, using a verification method specified by the Secretary.
Publication of Provider Directory Accuracy Scores
Starting January 1, 2028, the HHS Secretary would publish accuracy scores on the CMS website in a machine readable format. Additionally, MA plans would need to post their accuracy scores on their directory.
What's Next? Legislative Status and Future Updates
The REAL Health Providers Act is with the Committee on Finance. 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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