Surprise Medical Bills In Context: Is Tech the Solution?

By Fred Goldstein, MS and Gregg Masters, MPH

It’s Q1 2020 and everyone is now rightfully preoccupied with the recent World Health Organization (WHO) declaration of the COVID-19 as a global pandemic.

Congress, the White House, National Institutes of Health (NIH), the Center for Disease Control (CDC) and local state and county health departments (collectively the public sector) and private or commercial healthcare ecosystem stakeholders are scrambling to ‘flatten the curve‘ on the spread of this novel coronavirus.

One of the many issues being debated includes who bears the cost burden, whether there should be co-pays or deductibles and whether the public health sector and private healthcare delivery and financing system can get on the same page to aggressively test the population at scale, and incidentally avoid the downstream drama of surprise medical billing. This will get interesting folks!

Meanwhile, some forty years have passed since ‘selective contracting’ or the managed care era launched in California and spread across the nation, driving the need for more accurate and complete databases to effectively drive ‘in-network’ utilization for health plan and managed care organization members, beneficiaries and patients. However, inaccurate provider directory information, both online and in print, is still common and often leads to (directly or indirectly) ‘surprise medical bills.’

Over the past few years the issue of in and out of network providers and ensuring patients can identify which providers are in network has received considerable attention. Almost everyone has a personal story ranging from annoyance to distress about the difficulty of finding the right in-network doctor or choosing a health plan — which is hard to reconcile in our otherwise digitally enabled information age.

Not only are accurate provider directories critical for health plan selection and referrals to appropriate care, it helps ensure that patients do not suffer the financial burden of having unintentionally gone to an out of network provider. In 2019, surprise medical bills associated with out of network providers has become a major political issue, with Congress this past year attempting to develop and pass legislation aimed at reducing the negative impact on patients.

In an article entitled ‘Surprise bills vary by diagnosis and type of admission’[1] the authors estimated that 18% of all emergency room visits and 16% of inpatient admissions resulted in at least one out of network bill.

While according to a 2018 survey[2] by the American Medical Association (AMA) and LexisNexis® Risk Solutions, more than half of U.S. physicians (52 percent) say they encounter patients every month with health insurance coverage issues due to inaccurate directories of in-network physicians.

This  issue not only impacts patients and their ability to access the care they need without experiencing a financial burden, but also the overall patient satisfaction for providers and facilities, who often times will hear from upset patients about unexpected out-of-network bills.

This is also a costly business issue for health plans and providers — It is estimated that health plans spend upwards of $2.1 billion per year maintaining their directories[3] including on provider outreach efforts. On the receiving end, providers may work with a dozen health plans, each with quarterly campaigns to keep their directories updated. In a climate of provider fatigue and strained plan-provider relations, this is both figuratively and literally adding more paper on our overflowing desks.

In 2015, California took a lead in seeking to solve this issue by passing SB-137 Health care coverage: provider directories. This bill recognized the importance of an accurate provider directory as the key piece to solving these issues.

This legislation requires:

a health care service plan, and a health insurer that contracts with providers for alternative rates of payment, to publish and maintain a provider directory or directories with information on contracting providers that deliver health care services to the plan’s enrollees or the health insurer’s insureds, and would require the plan or health insurer to make an online provider directory or directories available on the plan or health insurer’s Internet Web site, as specified.

It also:

requires a plan to review and update their directory at least annually and to update its online provider directory or directories, at least weekly. 

That’s a tall order given the systems that health plans already had in place at the time. In an effort to meet compliance requirements, plans initiated even more outreach but the accuracy of provider directory data See CMS report: “Online Provider Directory Review Report”. Furthermore, many updates requested by providers did not end up reflected accurately in a plan’s member directories.

Shortly after SB 137 was passed, Blue Shield of California was tasked by the California Department of Managed Health Care (DMHC) to tackle the industry-wide provider directory inaccuracies in California as part of a large set of industry undertakings associated with their merger with Care1st (now Promise Health Plan).

Non-profit organization, Integrated Healthcare Association (IHA) was selected by Blue Shield, the California Department of Managed Care (DMHC) and a multi-stakeholder committee to lead the roll-out of a statewide solution for all plans and providers in California. This centralized platform, launched in 2019 as a the single place for healthcare providers and commercial, Medicare, and Medi-Cal health plans to update and reconcile the demographic and contractual information including primary phone number, address, specialty and accepting new patient status — information that patients ultimately depend on to make decisions about access and care.

[NOTE: On PopHealth Week we chat with IHA’s President and CEO Jeff Rideout. To listen, click on PopHealth Week logo.]

In a white paper summarizing results from the first year of Symphony’s roll-out in California, a baseline and early analysis shows that:

  • Nearly 30,000 records[4] contained at least 1 major provider identification issue that could cause significant consumer confusion
  • 317 records4 service locations listed are actually PO boxes
  • Nearly 4,000[5] unique providers were listed with a specialty inconsistent with their medical degree/training
  • 2765 unique providers still listed were actually deceased

While initial results are promising, a lot of work remains as more plans and providers onboard with Symphony. This data is a snapshot of how inaccurate current provider data can be. Understanding this baseline enables plans and providers to actionably correct these errors, leading to more accurate and up to date member directories and a more positive impact for patients, providers and payers.

The new white paper from the Symphony Provider Directory can be downloaded You can also learn more by watching this video or by going here.



[1] Pollitz, K., Rae, M., Cox, C., & Kurani, N. I. (2019, December 9). Surprise bills vary by diagnosis and type of admission. Retrieved from

[2] Physicians, health plans must collaborate for network directory accuracy. (2018, February 27). Retrieved from

[3] Issue Brief: Administrative Provider Data. CAQH [Analysis completed by Booz & Co., now Strategy&, Inc.]

[4] Based on 475,000 provider data records 

[5] Based on 160,000 unique providers


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