Provider directory accuracy: The 10 checks that prevent member misfires

If members can’t reach the doctor your directory promised, they don’t just feel let down- they churn, complain, and lose trust. In Medicare Advantage (MA), CMS’s audit of online provider directories found 48.74% of listed locations had at least one error: wrong number, wrong address, or “accepting new patients” marked when they were not. That’s a serious access problem and a complaint magnet.

Regulators have tightened the screws since. MA plan materials must be clear, accurate, and standardized, and provider directories now explicitly include each provider’s cultural and linguistic capabilities (including ASL) so members can find care they can actually use. This isn’t a “nice to have”; it’s in the rulebook.  

You’re likely juggling Stars, CAHPS, network ops, and complaint risk. This guide cuts through the noise. You’ll get 10 concrete checks, the ones that stop misroutes and reduce grievances mapped to owners, data sources, and KPIs, all aligned with current CMS rules and evidence. We’ll also walk through Pedro’s story, a real‑world member journey that shows where things break and how these checks prevent it.

‍What is provider directory accuracy and why does it matter?

Provider directory accuracy means a member can contact and book with the right in‑network clinician, at the right site, using the correct phone, with clarity on accepting‑new‑patients, language, and accessibility. In MA, CMS’s review found 48.74% of locations had at least one inaccuracy. Those errors drive barriers to care, grievances, and churn.

What the rules require now (Medicare Advantage + a practical baseline)

1. MA clarity and disclosure- Under 42 CFR §422.111, MA organizations must give members accurate, usable information about the number, mix, and distribution of in-network providers and indicate if a provider is accepting new patients.

2. Language and cultural capability in directories (CY2024)- MA directories must show providers’ cultural and linguistic capabilities, including languages available through the provider or a skilled interpreter (e.g., ASL). This is now explicit in CMS’s 2024 final rule.

3. Provider Directory API timing- Directory information (name, address, phone, specialty) must be available to the public within 30 calendar days of the plan receiving new or updated information.

4. Useful baseline many plans adopt (NSA)- The No Surprises Act requires a 90-day verification process, a procedure to remove unverified entries, and two-business-day posting after receiving changes. Though aimed at group/individual coverage, the cadence is widely adopted across lines of business to simplify governance and reduce risk.

The member story

Pedro is 72 and on your MA plan. His GP wants him to see a cardiologist this week. Pedro searches his plan’s directory, chooses the closest in‑network clinic, and calls. The number is dead. He tries another listing; the receptionist says the doctor left the network months ago. On the third call, he gives up and heads to the hospital. A few days later, Pedro tells his son he’ll switch plans at AEP.

What went wrong?

- The phone was wrong.
- The network status (by location) was wrong.
- The accepting‑new‑patients flag was stale.

What would fix it?

- A live contactability check before publishing.
- Site‑specific network status governed by your contract system.
- A dated accepting‑new‑patients field, verified regularly.

Now replay Pedro’s day after these fixes: the first call connects, the clinic confirms his plan and language needs, and he books Thursday morning. No complaint, no detour, no churn.

‍The 10 checks that prevent member misfires

Each check includes what to do, how to validate, and a metric you can track weekly.
‍
1. Identity & license match

Do: Confirm NPI, legal name, taxonomy and active state license.
Validate: NPPES/NPI Registry; state licensure boards.
Metric: % of providers with verified NPI/taxonomy/license.

2. Reachable phone (contactability)

Do: Test every number, automated dials daily on changed records; human spot‑checks monthly.
Validate: Bot dial results plus short “secret shopper” samples (CMS used call‑outs in its directory audits).
‍Metric: Contactability rate (connections within three rings).

3. Mailable, mappable address

Do: Standardize, geocode, and flag low‑confidence matches for manual review.
‍Validate: USPS address tools + geocoding; bounce‑backs.
‍Metric: % validated addresses; % with high geocode confidence.

4. Network status by site and plan

Do: Publish in‑/out‑of‑network at the location level and by line of business/tier; remove terminated sites quickly.
‍Validate: Contract master, roster change events, termination notices.
‍Metric: % of site‑level network statuses correct on audits.

5. Accepting‑new‑patients (ANP) with date stamp

Do: Display ANP with last‑verified date; verify during attestations and call samples.
‍Validate: Provider attestation and periodic “secret shopper” calls; CMS has long expected directories to note ANP status.
‍Metric: ANP accuracy on sampled calls.

6. Languages & accessibility

Do: Record spoken languages (including ASL), interpreter availability and accessibility features (e.g., wheelchair access).
‍Validate: Provider attestation aligned to MA rule; publish in directory profile.
‍Metric: % of profiles with language & accessibility fields complete.

7. Services & modality (telehealth vs in‑person)

Do: Indicate whether a service is delivered in‑person, via telehealth, or hybrid; show clear booking instructions.
‍Validate: Provider attestation; contract service lists.
‍Metric: % of profiles with accurate modality tags.

8. Hospital/facility affiliations

Do: Keep active admitting/affiliation info current to support referrals.
‍Validate: Group and facility rosters; credentialing feeds.
‍Metric: Affiliation match rate on quarterly spot‑checks.

9. Sanctions & exclusions sweep

Do: Screen against HHS‑OIG LEIE on a fixed cadence; quarantine hits and notify Compliance.
‍Validate: LEIE lookups (monthly is recommended in federal guidance to states and widely adopted by plans).
‍Metric: % of active panel cleared monthly.

10. Cadence & audit trail (governance)

Do: Run a 90‑day verification drumbeat, update member‑visible fields within 2 business days of change, and keep an immutable timestamped audit trail. Your Provider Directory API should be updated within 30 days at the outside.
‍Validate: Workflow logs; API publish timestamps; policy for suppressing unverified entries.
‍Metric: Time‑to‑publish (median/90th), verification coverage, suppression rate.

How to operationalize these checks

1. Create one source of truth
Feed web, PDF, call‑center tools, and the API from a governed provider data hub rather than scattered spreadsheets.

2. Automate authoritative inputs
Pull NPPES nightly, licensure weekly, contract events in real time.

3. Schedule verification
Auto‑trigger attestations by segment at least every 90 days; suppress entries that miss verification under your policy.

4. Instrument contact tests
Robot‑dial changed numbers daily; run small “secret shopper” samples monthly. CMS itself used direct calling in its directory reviews.

5. Standardize addresses
USPS standardization, then geocode; route low‑confidence results to humans.

6. Wire fast publishing
Push changes to the Provider Directory API within 30 days and aim for ≤2 business days on member‑visible web pages for phones, addresses, and network status.

7. Run exclusions monthly
Check LEIE, quarantine hits, document outcomes.

8. Make it easy for members to report errors
Add a “Report an error” link and a warm‑transfer number; route submissions back to Data Ops.

9. Prove it on demand
Keep change history, attestation receipts, call logs, and publish timestamps. That’s your audit pack.

Digital front door: Let members ask and then get an answer

Your directory shouldn’t make seniors guess. Use plain‑English (and multilingual) search, phone‑first options, and short questions that reduce choice paralysis. Include language filters, “accepting‑new‑patients” toggles, and signals for parking, lifts, and telehealth.

Mia, a member retention platform for health plans, helps your members find nearby providers just by asking, in their own language. Include Mia as your strategic partner so people like Pedro can simply speak or type what they need and get the right match.

‍The data sources you should validate against‍

- Identity & taxonomy: NPPES/NPI Registry for legal name, NPI and taxonomy.  

- Licensure: State board status/expiry for each provider.

- Contracts: Your contract master (drive site‑level network status from here).

- Exclusions: HHS‑OIG LEIE (monthly cadence widely adopted).  

- Member‑facing content rules: 42 CFR §422.111 and CMS model materials (ANP notation).‍

- Publishing SLA: Provider Directory API (public and updated within 30 calendar days); many teams adopt 2‑business‑day internal SLAs for member‑visible pages based on No Surprises Act verification and update cadence.

‍How to measure directory accuracy every week

- Contactability rate: % of phone numbers that connect (bot + human checks).

- ANP accuracy: % where “accepting‑new‑patients” matches call sample results.  

- Time‑to‑publish: Days from validated change to live; target ≤2 business days for phone/address/network, ≤30 days for API.  

- Verification coverage: % of profiles verified in the last 90 days (aim for 100%).  

- Ghost rate: % of sampled listings unreachable/not at location/not in network; trend down over time (CMS found broad accuracy issues through secret‑shopper‑style calling).  

- Member‑reported error close time: Average days to fix a reported error.

- Complaint linkage: Count and rate of grievances tied to directory errors.

‍90‑day implementation plan

Weeks 1–2: Prepare

- Form a cross‑functional squad (Provider Data Ops, Network, Compliance, Digital, Call Centre).

- Pick the single source of truth and define fields that trigger immediate publishing (phone, location, network status, ANP, language).

Weeks 3–6: Wire the data

- Automate feeds (NPPES nightly; licensure weekly; contracts in real time).  

- Stand up robot dialing and address standardization.

- Define suppression rules for unverified entries (NSA‑style) and log everything.

Weeks 7–10: Prove accuracy

- Launch monthly call samples to detect ghosts; fix quickly. CMS used this approach in its reviews.

- Add a “Report an error” link and route to Data Ops.

- Populate language/cultural fields and surface them in search.  

Weeks 11–12: Lock governance

- Demonstrate ≤2‑day publishing for critical fields; show ≤30‑day API updates.  

- Review weekly KPIs with executives; set targets for next quarter.

Why this matters for retention

Directory friction shows up as repeated calls, avoidable urgent‑care visits, and low trust- especially for seniors who prefer the phone and need quick answers. When your team runs on a 90‑day verify / 2‑day update rhythm and keeps the Provider Directory API inside 30 days, complaint volume drops and members find care faster. That reduces switching during AEP and supports member‑experience measures in Stars.  

‍FAQs

How often should an MA plan verify provider directory information?
Keep your Provider Directory API current within 30 days of receiving updates. Many teams also adopt the No Surprises Act baseline- verify every 90 days and post changes within 2 business days to simplify operations and reduce risk across lines of business.

Which fields cause most “member misfires”?
Phone, location, site‑specific network status, and accepting‑new‑patients. CMS found nearly half of locations had at least one inaccuracy.  

Do MA directories really need language details?
Yes. MA directories must include providers’ cultural and linguistic capabilities (e.g., availability of ASL).

Are “secret shopper” calls acceptable?
Yes. CMS’s own reviews used direct calls to verify accuracy-an effective way to detect dead numbers and ghost entries.

Should profiles be suppressed if a provider won’t attest?
Yes, if your policy mirrors the No Surprises Act approach: remove entries you cannot verify within your specified period and republish once verified.  ‍

Conclusion

Make this your north star for every profile: Can members reach this clinician, at this site, under this plan, in their language? When each part is a clear “yes”, three things happen. Members book faster and stay put because the journey feels simple and respectful. Clinicians trust the plan because referrals arrive with the right coverage and expectations. And the directory stops being a liability and starts working like a reliable front door- quiet calls, fewer grievances, and steady stars.

Please note: This article provides general information for MA plans. Confirm requirements with CMS regulations and your legal counsel.