Every health plan leader has heard the complaint. A member calls the listed cardiologist, and the number belongs to a pizza shop. It sounds funny until that member files a grievance. Now CMS wants to turn that complaint into a published grade.
On October 16, 2026, CMS proposed new Medicare Advantage provider directory requirements under the REAL Health Providers Act. The proposed rule in the Federal Register would require plans to verify most listings at least every 90 days. Plans would also run an annual accuracy analysis, and CMS would publish the scores. The requirements begin with contract year 2028, and comments close on December 15, 2026.
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Why the REAL Health Providers Act Changes Provider Directory Accuracy
Until now, most plans treated directory errors as an audit exposure. Auditors found them occasionally, and plans fixed them quietly. In contrast, this rule makes accuracy a competitive number that brokers, members and regulators can compare.
The rule also builds on an earlier change. Since 2026, plans have submitted directory data for display on Medicare Plan Finder. We covered that shift in our analysis of why public provider directories change CMS compliance. That rule made mistakes visible to members. This proposal goes further, because it grades those mistakes.
CMS Administrator Mehmet Oz framed the goal plainly in the agency’s announcement. “CMS has been working to improve data connectivity and accuracy in provider directories across the healthcare system,” Oz said. Regulators, in other words, now see directory data as infrastructure rather than marketing copy.
What the CMS Provider Directory Rule Would Require
The proposal covers network-based plans, including coordinated care plans, cost plans and PFFS plans with contracted networks. It excludes non-network regional PPOs and PACE organizations. The main obligations look like this.
Plans must also add contract language that obliges providers to keep their information current. That clause sounds simple on paper. However, enforcing it across thousands of independent offices is another story entirely.
How the Provider Directory Accuracy Score Would Be Weighted
Not every data element counts equally. According to an independent analysis of the proposed rule prepared for the Missouri Hospital Association, CMS proposed specific weights. Network participation status carries 40% of the score. Contact information and office address carry 20% each, while specialty carries 10%.
The remaining elements share the last 10%. Disability accommodations and telehealth capability each carry 3.5%, and accepting new patients carries 3%. Consequently, three elements decide 80% of any plan’s grade.
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This weighting rewards discipline inside the plan as much as outreach outside it. Network status lives in the plan’s own contracting systems. Therefore a terminated contract that never reaches the directory is both the costliest error and the most avoidable one.
Phone numbers and addresses behave differently. Practices move, merge and change numbers without telling anyone. As a result, plans can only confirm them by reaching the office or matching trusted data sources.
One warning deserves attention here. New-patient status counts for little in the score, yet members care about it most. A plan that chases the grade alone may still lose the member.
Ghost Networks Put Behavioral Health at the Center of the Sample
The proposal draws 35% of each sample from high-inaccuracy specialties. For now, CMS limits that group to mental health and substance use disorder providers. That choice reflects years of evidence about so-called ghost networks.
A Real-World Example: The Senate Secret Shopper Study
In 2023, Senate Finance Committee staff called 120 listed mental health providers. The calls covered 12 Medicare Advantage plans in six states. They secured an appointment only 18% of the time, according to the committee’s secret shopper report. A third of the listings had wrong or dead numbers or calls nobody returned.
Senator Ron Wyden, then the committee chair, did not soften his verdict. “The widespread existence of ghost networks is unacceptable,” he said when releasing the study. CMS now cites similar federal findings, including an OIG review of inactive behavioral health providers.
across 120 listed providers
or no returned calls
tested in 6 states
Behavioral health records resist standard verification for practical reasons. Many therapists work solo, practice part-time or see patients only by video. Few of them employ someone to answer a plan’s verification call. Accordingly, plans need a separate cadence for this group, built around email, attestation and claims activity.
Provider Data Management at a 90-Day Cadence Is a Staffing Question
Quarterly verification sounds like a policy update. In practice, it behaves like a capacity plan. Consider an illustrative plan with 20,000 unique provider-location records.
Verifying each record four times a year creates 80,000 verification events. That works out to roughly 1,540 every week, before anyone redials a busy office. The real workload depends on how many records a plan can confirm without a human conversation.
Fortunately, CMS allows several methods. Plans can use internal data, phone and email outreach, provider attestations, claims data and federal sources such as NPPES. A smart model confirms stable records from data, calls the conflicting ones and escalates the unreachable ones for flagging.
Provider abrasion is the cost nobody budgets for. A busy practice may hear from every contracted plan every 90 days. One well-scripted call that captures every element beats three narrow calls. Our guide to modern provider data management for health plans explains how plans structure that outreach.
CMS estimates industry costs at roughly $6 million in 2028, according to the same analysis. That analysis argues the figure understates the true burden. Plans should build their own estimate from record counts and real contact rates.
Cost-Sharing Protection Turns the Directory Into Evidence
The member protection may surprise operations teams most. Suppose a member sees an out-of-network provider whom the directory listed as in network. That member pays no more than in-network cost sharing, and the amount counts toward the out-of-pocket maximum.
According to the analysis, plans must apply this protection whenever they know or should know it applies. Plans establish the appointment date from provider scheduling records first and provider attestation second. If neither exists, the member gets the benefit of the doubt.
Directory history therefore becomes evidence. Plans will need dated snapshots of every listing, kept for more than ten years. Meanwhile, claims teams need logic that spots these cases, and member services agents need scripts that recognize them.
That last point matters more than it seems. A member who says “your directory told me she was in network” may be starting a coverage request. Agents who treat it as a routine complaint create compliance risk. Similar appointment-access scrutiny already applies to exchange plans, as our breakdown of QHP secret shopper requirements shows.
How Health Plans Can Prepare Before 2028
The rule remains a proposal, so details may change before CMS finalizes it. Even so, several moves make sense now. First, plans should submit comments by December 15, particularly on the facility scope and low-enrollment exception.
Next, plans should score themselves early. A random sample using the proposed 65/35 split and weights shows the gap before CMS publishes it. Additionally, contracting and directory teams should automate terminations so departed providers disappear within five business days.
Plans should also update 2028 provider agreements, build the snapshot archive and train member services on the new protection. Finally, leaders should size outreach capacity honestly. Strong provider network management and verification work rarely fits inside an already stretched network team.
So here is the question worth debating with your peers. Will public accuracy scores finally end ghost networks, or will plans simply learn to pass the test?
Get Ready for 90-Day Directory Verification With Ameridial
Ameridial keeps health plan listings accurate through provider data management services. That work combines directory audits, change processing and outbound verification calls. Our healthcare-trained teams contact provider offices, confirm each data element and document every result for audit readiness.
If your plan wants to know what a 90-day verification cycle will demand, let’s map it together. Book a consultation with Ameridial to review your volumes, contact rates and readiness gaps. Then you will know your score before CMS publishes it.
