Using Machine-Readable Provider Directories in Medicare Advantage Plans

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Many health insurance carriers, including those that offer Medicare Advantage (MA) plans, are employing narrow provider networks. But because the provider lists and directories that plans release are often inaccurate, beneficiaries can be unaware of the size and scope of a plan's network when they enroll. Moreover, using existing resources, it is nearly impossible to create a searchable database of network information for either regulatory or research purposes. Machine-readable provider directories, which configure information in a standardized electronic format for aggregation by computers, offer one possible way to create accessible information on provider networks. Such directories are already the norm in the federal health insurance marketplace and will become the standard in Medicaid, per regulation, in 2018. Yet in the MA program, machine-readable directories remain just a recommendation, even as the Centers for Medicare and Medicaid Services (CMS) devotes more resources to manually auditing MA plans for provider network adequacy and provider directory accuracy. A team, including researchers from NORC at the University of Chicago, will examine the potential benefit of having a standardized (i.e., machine-readable) electronic format for provider directories in the MA program. Focusing on one zip code in each of five states where the same health insurer offers both MA and marketplace plans, the team will compare machine-readable provider directories to non-machine-readable provider lists with respect to the following questions: How much of the information from machine-readable directories and the MA directories currently in use can be verified as accurate (through phone calls to provider offices)? Is information from machine-readable directories more accurate than that from prevailing MA directories? How much did MA provider networks change from 2016 to 2017? The study will also assess the relative burden for regulators and MA plans to maintain and monitor the accuracy of directories. Project findings will inform CMS of the potential of machine-readable provider directories to assist beneficiaries in choosing providers and plans and to allow the agency to more easily and accurately audit and manage the lists. The findings will also be of interest to consumer groups, health insurers, and researchers.

Grant Details

Grantee Organization:
Faegre Baker Daniels LLP
Principal Investigator:
Michael Adelberg, M.A., M.P.P.
Award Amount:
$65,000.00
Approval Date:
July 11, 2017

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