Imagine visiting a doctor you believe is covered by your insurance, only to later receive an unexpected, hefty bill. Sound familiar? You’ve fallen victim to surprise medical billing. And a significant culprit behind this issue is inaccurate provider directories.
Surprise medical billing occurs when you visit a doctor you think is part of your insurance network, but later discover they’re out-of-network. This leaves you responsible for a larger portion of the bill than anticipated. Several reasons can lead to surprise billing, including:
- Being referred to an out-of-network specialist
- Outdated information in provider directories
- Getting emergency care from out-of-network doctors
- Receiving services from out-of-network providers during a procedure
- Delayed updates to a doctor’s network status
The Problem with Provider Directories
Now, let’s talk about those pesky provider directories. According to a study published by JAMA Open Network, five of the largest health insurers have inconsistencies in 81% of their physician directory entries. This can occur due to staffing shortages as insurance contracts rapidly evolve, or even intentional deception to gain a competitive edge. Regardless of the cause, inaccurate directories can harm patients significantly.
Relying on outdated or incorrect provider directories can lead you to unintentionally choose an out-of-network doctor, resulting in a surprisingly high bill. This can cause major financial stress, not to mention medical and emotional strain.
The Need for Technological Solutions
So, what’s the solution? Despite the introduction of laws like the “No Surprises Act” and initiatives by the Centers for Medicare and Medicaid Services (CMS), inaccurate provider directory data remains a pressing issue. To effectively address this problem, health insurance companies should invest in technological solutions to modernize how they track, verify, and share provider information.
Upgrading outdated technology can help restore trust with healthcare consumers and reduce the exorbitant administrative costs associated with managing provider data. Automated systems that monitor provider changes and offer real-time updates can help insurance companies maintain current directories and inform members promptly when a doctor leaves their network or makes other changes.
Taking Action for Change
With billions of dollars being poured into healthcare AI, insurance companies and healthcare providers can allocate a portion of their operating budget to enhance the foundation of their financial relationship: provider networks and data management.
Insurance companies should prioritize protecting members from unexpected coverage gaps and excessively high bills. By investing in technology to prevent outdated provider listings, they can ensure patients have accurate information when making healthcare decisions.
Inaccurate provider directories significantly contribute to the issue of surprise medical billing in the US. By investing in technology to modernize provider data management, insurance companies can safeguard patients from financial, medical, and emotional distress while restoring trust in the American healthcare system.
To learn more about how Virsys12 can help your healthcare organization with enterprise provider data management efforts, please contact us today.
