Provider Directory Accuracy for Payers: The Hidden Lever for Better Care
Provider directories are more than a member lookup tool—they power network adequacy, care navigation, claims, and quality programs. Here’s why accuracy matters to payers and how to improve it.
Provider directories are often treated like a compliance checkbox: keep a list of clinicians, locations, and phone numbers, publish it, update it "often enough," and move on.
But for payers, directory accuracy is a foundational data problem and a measurable driver of:
Member experience
Can members find in-network care when they need it?
Clinical outcomes
Do members get the right care in time?
Medical cost and leakage
Do members end up out of network, in the ED, or delaying care?
Regulatory risk
Network adequacy oversight and consumer protection rules
In other words: an accurate directory isn’t just good patient access—it’s part of good care.
Here’s why directory accuracy matters, what tends to break, and what "good" looks like in practice.
Key Takeaways
- >Directory accuracy directly affects access, continuity, and affordability — especially for behavioral health, where “ghost” listings can make networks appear larger than they are. [5]
- >In a 2023 JAMA study comparing major insurer directories, only ~19% of physician listings were consistent across all directories for key attributes like address and specialty. [1]
- >Federal policy increasingly treats directory errors as member harm, not inconvenience. Under the No Surprises Act, when someone relies on incorrect directory information and inadvertently receives out-of-network care, cost sharing must be limited to in-network terms. [3]
- >Modern directory programs look more like a governed product with one canonical data model, clear ownership, automated verification, and metrics tied to access and quality.
What a payer "provider directory" really is
Most people picture a directory as a web page that helps members search for in-network clinicians. That’s only the surface.
As a payer, the directory is a network data asset that influences and feeds multiple systems and decisions:
- Digital navigation and find-a-doctor experiences
- Call-center workflows and scripts
- Referral routing and prior authorization logic
- Claims adjudication and out-of-network determinations
- Value-based contract attribution and quality measurement
- Network adequacy reporting and regulatory submissions
- Delegated entity oversight (PBMs, TPAs, specialty networks)
When the directory is wrong, it’s not just a "bad search result." It can cascade into avoidable rework, member abrasion, delayed care, and cost.
Why accuracy matters specifically to payers
Network adequacy depends on directory truth
Network adequacy is often evaluated using the payer’s own network data. If directory listings include clinicians who are inactive or unreachable, the network can look adequate on paper while being functionally inaccessible. [4]
The HHS Office of Inspector General (OIG) found that for selected plans’ behavioral health networks, a large share of listed providers were inactive. In the OIG’s analysis, 55% of listed behavioral health providers in Medicare Advantage networks were inactive on average (28% in Medicaid managed care).[5] OIG notes these "ghost" listings can make networks appear larger than they truly are.
Payer implication: directory accuracy becomes the baseline for whether network adequacy oversight is meaningful and whether access standards can be met in practice.
Directory errors create member harm and surprise costs
Directory inaccuracies don’t just frustrate members, they can change where care happens and what it costs.
In a survey-based study in Health Affairs, adults searching for outpatient mental health care often encountered directory inaccuracies. Those who encountered inaccuracies were more likely to receive out-of-network care and more likely to receive an outpatient surprise medical bill.[8]
Federal rules now explicitly treat this as a consumer protection issue. A CMS training on the No Surprises Act explains that when an individual relies on incorrect directory information and receives care from an out-of-network provider or facility as a result, plans must limit cost sharing to what would have applied in network, and providers/facilities may not bill beyond in-network cost-sharing.[3]
Payer implication: directory inaccuracy can convert into direct cost and complaint volume, not merely a bad member experience.
Poor directory data distorts quality and value-based programs
If your directory can’t reliably answer "who practices where, and for whom," downstream programs suffer:
Attribution & continuity
Misattributed members and disrupted care teams
Quality measurement
Flawed denominator/attribution logic for quality programs
Steerage & navigation
“Preferred” routes that don’t exist in reality
Risk & equity analysis
Incorrect geographic access and disparity assessments
In a JAMA analysis of major insurer directories, physician information such as address and specialty frequently disagreed across directories.[1] When different payer directories disagree about the same clinician, any workflow relying on directory data becomes less trustworthy.
Payer implication: directory accuracy should be treated as a prerequisite for good operations, not separate.
Administrative burden has a real price tag
Directory updates remain highly manual in many markets. Providers receive repeated, duplicative requests from multiple plans and delegated entities, often in different formats and cycles. This creates friction for providers and delays for payers.
Even public policy groups have noted the need for coordinated, standardized provider data exchange to reduce administrative burden and improve accuracy.[10]
Payer implication: improving directory accuracy can reduce provider abrasion and support more durable network relationships.
What breaks directories in the real world
Directory inaccuracies aren’t typically caused by one "bad provider file." More commonly, they emerge from structural issues:
“Identity” and hierarchy problems
- One clinician, multiple NPIs (individual vs organization), multiple affiliations
- Group practices with multiple locations and sublocations
- Mergers/acquisitions that change names, tax IDs, and location lists
“Availability” errors
- Is the provider actually accepting new patients?
- Do they accept this product/network/coverage?
- Can I actually schedule using the phone number listed on the payer’s directory?
- Is the location accurate, still open, and does it offer the services required?
Even when the underlying provider is "in network," any mismatch in these details functions as "no access."
Update latency and verification gaps
In a Pennsylvania Department of Insurance analysis, using repeated "secret shopper" surveys of ACA Marketplace plans, a substantial share of providers continued to have at least one inaccuracy months later, suggesting that inaccuracies can persist even under stronger regulatory expectations. [9][6]
Measurement blind spots
Many payers measure "directory accuracy" using internal reconciliation against upstream files. That can miss the member’s real experience: can the member reach the office and schedule that provider?
The Government Accountability Office (GAO) used covert calls to assess accuracy in TRICARE behavioral health listings and reported that most sampled listings were inaccurate, with problems such as incorrect locations or phone numbers, issues directly affecting appointment access.[7]
Directory accuracy as a product
With directory accuracy being foundational, high-performing payers apply product thinking and governance:
Define one canonical directory data model
A directory model should represent not just providers, but:
- Providers ↔ organizations ↔ locations ↔ networks/products
- Service types, specialties, and modalities (in-person vs telehealth)
- Panel status / accepting-new-patients status (and its effective date)
- Contact routes for scheduling vs referrals vs medical records
- Verification status and "last confirmed" timestamps, for all data elements
Use standards and APIs where possible
CMS has required certain impacted payers (e.g., Medicare Advantage organizations and Medicaid managed care plans) to offer a public Provider Directory API and specifies a set of required information elements (e.g., provider names, addresses, phone numbers, specialties) and timeliness expectations.[2]
Even if your line of business isn’t explicitly covered by these requirements, the architectural direction is clear: machine-readable directory data with defined update windows.
Implement continuous verification, not periodic cleanups
Operationally, the best directories behave like living datasets:
- Automated signals: returned mail, call outcomes, claims/encounters, scheduling reachability
- Provider attestation workflows: lightweight, role-based, and auditable
- Delegated entity SLAs: enforce format, timeliness, and verification requirements
Measure what members experience
Add "experience-based" metrics that reflect actual access:
Practical first steps for payers
If you’re building or upgrading a directory program:
Pick a specialty to pilot (behavioral health is often the highest-impact starting point).
Run a "member reality" audit using secret-shopper calls or similar verification on a statistically meaningful sample.[7]
Create one "source of truth" dataset and make downstream systems consume it (rather than each system owning its own copy).
Data lineage updates: every change should have an origin, timestamp, owner, and verification status.
Close the loop with operations: tie directory accuracy metrics to call center, navigation, and grievance outcomes.
The Bottom Line
Provider directories are one of the few payer-managed assets that directly shape a member’s ability to get care. When they’re wrong, people delay or forgo treatment, fall out of network, or experience outcomes that affect both health and cost.
The evidence is clear: directory inaccuracies are common,[1][7] can mask access gaps,[5] and are now explicitly addressed in federal consumer protections.[3] For payers, the path forward is to treat directories like care infrastructure: governed, measurable, and designed around real access—not just a published list.
References
- Butala NM, et al. "Consistency of Physician Data Across Health Insurer Directories." JAMA (2023). jamanetwork.com
- Centers for Medicare & Medicaid Services (CMS). "Provider Directory API (FAQs)." (Last modified 07/29/2025). cms.gov
- CMS. "The No Surprises Act’s Continuity of Care, Provider Directory, and Public Disclosure Requirements." (PDF). cms.gov
- CMS. "Online Provider Directory Review Report: Round 3." (2018, PDF). cms.gov
- U.S. Department of Health and Human Services, Office of Inspector General (HHS-OIG). "Many Medicare Advantage and Medicaid Managed Care Plans Have Limited Behavioral Health Provider Networks and Inactive Providers." OEI-02-23-00540 (Oct 2025, PDF). oig.hhs.gov
- Pennsylvania Department of Insurance. "Assessing the Persistence of Provider Directory Inaccuracies in Pennsylvania ACA Marketplace Plans Using Repeated Secret Shopper Surveys (Extended Version)." (PDF). pa.gov
- U.S. Government Accountability Office (GAO). "Defense Health Care: DOD Should Improve Accuracy of Behavioral Health Provider Information in TRICARE Directories." GAO-24-106588 (Jul 2024, PDF). gao.gov
- Busch SH, Kyanko KA. "Incorrect Provider Directories Associated With Out-Of-Network Mental Health Care And Outpatient Surprise Bills." Health Affairs (2020). healthaffairs.org
- Haeder SF, Zhu JM. "Inaccuracies in Provider Directories Persist for Long Periods of Time." Health Affairs Scholar (2024). healthaffairs.org
- U.S. Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation (ASPE). "State Efforts to Coordinate Provider Directory Accuracy: Final Report." (2023). aspe.hhs.gov
- Gollust S, et al. "Potemkin Protections: Assessing Provider Directory Accuracy and Timely Access for the Federal Marketplace." Journal of Health Politics, Policy and Law (2022). dukeupress.edu