Your Medicare Advantage Listing Could Become Contract Work

An outdated phone number or open-panel flag can turn a directory search into another failed call. CMS now proposes Medicare Advantage directory rules that would reach practices through contract terms.

CMS issued CMS-4214-P on October 16; the Federal Register published it October 20. It implements section 6220, the REAL Health Providers Act, of the Consolidated Appropriations Act, 2026, enacted in February. Comments are due December 15.

Section 6220 requires Medicare Advantage plans to verify the directory information of every listed clinician at least once every 90 days, and the proposed rule would apply that requirement starting in contract year 2028. The information includes name, specialty, contact details, the address where services are furnished, new-patient status, disability accommodations, languages and cultural capabilities, and telehealth capability.

Plans could verify by phone, email, provider attestation, claims data, or CMS data. If a plan cannot verify a listing, it must say so in the directory; CMS's suggested wording is "The provider's information may not be up to date." Once a plan determines that a clinician has left the network, it must remove the listing within 5 business days.

Today, Medicare Advantage plans must update online directories within 30 days of receiving information requiring an update and attest at least annually to CMS that submitted directory data is accurate. CMS's manual says plans should contact providers quarterly, but no regulation sets a verification cycle. Commercial plans have had a 90-day requirement under the No Surprises Act.

The statute places the verification duty on plans; the proposed rule reaches practices through two contract terms. One obligates the clinician to keep directory information current and accurate. The other requires supplying documentation of the earliest date a patient's appointment was made, regardless of rescheduling, and survives the contract's end for at least 10 years.

That record matters for a patient protection. For an otherwise covered service, if an enrollee books with a clinician who is listed in the plan's online directory on the day the appointment is made but is not in the network, the plan would have to apply the lesser of in-network cost sharing or the cost sharing that would otherwise apply. If the plan collects more than that, it would have to refund the excess. CMS places the burden of proof on the plan. If the plan cannot obtain documentation in time, the protection would apply by default, which the plan could reverse if it clearly shows the protection does not apply. Documentation could be a scheduling record, a confirmation sent to the patient or, failing those, a signed provider attestation with corroboration. Plans will have reason to ask practices when appointments were first booked. The proposal does not specify a payment rate or settlement process for the nonparticipating clinician, although section 6220 adds these services to those the statute requires plans to reimburse when furnished outside the network.

CMS estimates 15 minutes of provider time per direct verification contact, or up to an hour a year at a 90-day cadence. It does not estimate the combined burden across plans; verification through plan records or CMS data would mean less outreach. Separately, the statute requires CMS guidance, due about February 2027, on when Part B clinicians should update NPPES, the national provider registry.

A listing the plan cannot verify during the 90-day cycle would be flagged, not removed. The No Surprises Act is stricter: commercial plans must have a procedure for removing listings they cannot verify, and clinicians have a direct statutory duty to supply directory information.

Plans would compute an annual accuracy score from a sample of listings, 35% of them from mental health and substance use disorder specialties, report it to CMS, and, from contract year 2029, display it on their directories.

OIG reported in October 2025 that, across 33 Medicare Advantage plans with network providers in 10 counties, an average of 55% of listed psychiatrists, psychologists, and clinical social workers provided no service to plan enrollees in 2023. Inactivity alone is not an error. Among responding inactive providers surveyed across Medicare Advantage and Medicaid plans together, OIG estimated that 72% should not have been listed: 46% worked at no listed location, 21% did not accept the plan, and 5% held administrative roles.

In a secret-shopper study published October 16 in JAMA Health Forum, Haeder and colleagues placed 5,822 calls to psychiatrists and psychologists listed in Blue Cross Blue Shield PPO directories in five states from October 2025 to March 2026. Most calls (61.3%) could not be evaluated. Among the 2,252 that could, adjusted directory-error estimates were 55.6% overall, 57.8% for psychiatry, and 52.8% for psychology. Callers checked contact, specialty, and network information in sequence and generally stopped at the first error, so the authors call the specialty and network-status rates conservative. Across all initial attempts, 12.4% yielded an appointment offer with the listed clinician or another clinician reached at the same number (9.1% with the listed clinician). These were offers, not bookings, and with one attempt per listing the authors call that yield a lower bound.

In the proposed score, each element is rated by how often it was accurate across the sample, then weighted. Of 100 points, network status carries 40, phone and contact details 20, address 20, and specialty 10. Accepting new patients carries 3, slightly less than telehealth capability or disability accommodations at 3.5 each. By that arithmetic, a plan whose new-patient flags were wrong for every sampled listing, and right on everything else, would still score 97, an A.

CMS argues that patients can still contact a clinician despite a wrong new-patient flag, and that panel status changes often. Accuracy scoring also differs from access standards, such as Medicare Advantage's 30-business-day standard for routine behavioral health appointments. Still, the flag is what a patient acts on. In the JAMA Health Forum study, a call counted as a capacity limit when the checked contact, specialty, and network fields were accurate but the clinician was not taking new patients; such limits blocked scheduling in 18.8% of evaluable psychiatry calls. The study did not test new-patient flags, so it cannot measure how often they are wrong.

The proposed requirements would not start before 2028 and may change. Some steps make sense now:

Under this proposal, keeping directory information accurate and supplying first-booked appointment dates would become contract terms, and the documentation obligation would survive leaving the network for at least 10 years.

Source note: This commentary summarizes a proposed rule, the statute it implements, current federal directory requirements and guidance, one federal oversight report, and one secret-shopper study. Proposed requirements may change in the final rule. The secret-shopper study covered commercial Blue Cross Blue Shield PPO plans in five states, not Medicare Advantage. Its error and capacity estimates were adjusted. The 12.4% and 9.1% figures are observed proportions of initial calls yielding appointment offers, not bookings or completed visits. The OIG survey figures pool Medicare Advantage and Medicaid managed care. The article does not assess any individual plan's directory, interpret any specific provider contract, or estimate a practice's compliance cost beyond CMS's own figures.

Educational Disclaimer: The Psychiatric Record provides general educational information for psychiatric and mental-health professionals. Content does not constitute medical, legal, regulatory, compliance, billing, or other professional advice; does not establish a standard of care; and is not a substitute for independent professional judgment. Contract obligations depend on the terms of each agreement and on final regulations. Practices should review specific contracts and obligations with qualified advisors.