Plans will be graded on directory data that providers hold. Medicare Advantage plans must verify their provider directories at least every 90 days starting in 2028. They must also remove departed clinicians within 5 business days. From 2029, each plan must display an accuracy score that CMS also publishes. The law behind those rules passed in February. CMS proposed how to carry it out in October.
The rules put the duty on plans, and that is fair. A plan sells access to its network, and the directory is how a member finds it. But the facts in a directory belong to someone else. Whether a clinician still practices at an address, or is taking new patients this month, is known first to the clinician’s office. A plan can only ask.
What we think plans and CMS should do before the first scores arrive comes at the end, and it starts with fixing directories at the source.
Key takeaways
- The law sets a clock. The REAL Health Providers Act requires verification at least every 90 days starting in 2028, according to the AMA.
- Departures must come off fast. Plans must remove clinicians who leave the network within 5 business days.
- Scores go public. Plans must display directory accuracy scores from 2029, and CMS will publish them in machine-readable form.
- Members are protected. A member who goes out of network because of a wrong listing would pay no more than in-network cost sharing.
- The data starts with providers. Plans will keep calling offices every 90 days unless clinicians can update their information once, in a place every plan can read.
- A national directory could help. CMS is building one, and data from the new rules could feed it. Who answers for its errors is still open.
What the rules require now
Directory rules for Medicare Advantage did not start this year. A rule CMS finalized in fall 2025 already requires plans to update their directories within 30 days of learning about a change, according to Healthcare Dive. Plans must also attest to accuracy each year. The same rule sends plan directory data to Medicare Plan Finder, where members compare plans, as our piece on ghost networks described.
Plan Finder raises the stakes. A member comparing plans in the fall now sees each plan’s network as the plan reported it. A wrong listing there can steer an enrollment decision for a full year.
Those rules depend on the plan learning about a change. A plan that is never told a clinician moved has nothing to update. The 30-day clock starts only when the plan knows.
The new law closes that gap by requiring plans to go looking. The Requiring Enhanced and Accurate Lists of Health Providers Act, known as the REAL Health Providers Act, passed as part of the Consolidated Appropriations Act, 2026. It sets standards for verifying directory data, not just for updating it.
| Date | Step |
|---|---|
| Fall 2025 | CMS rule requires updates within 30 days of learning of a change |
| February 2026 | The REAL Health Providers Act becomes law |
| October 2026 | CMS proposes rules to carry out the law |
| 2028 | Verification and member protections begin |
| 2029 | Plans display accuracy scores, and CMS publishes them |
What the 2026 law adds
The law’s requirements begin in 2028, according to the AMA.
| Requirement | Standard | Starts |
|---|---|---|
| Verification | Every 90 days for clinicians and every 12 months for facilities | 2028 |
| Unverified listings | Flagged as possibly out of date | 2028 |
| Departures | Removed within 5 business days | 2028 |
| Accuracy audits | Annual statistical audits, with scores reported to CMS | 2028 |
| Public scores | Displayed in each plan’s directory and published by CMS | 2029 |
| Member protection | In-network cost sharing when a wrong listing leads to out-of-network care | 2028 |
The law also standardizes what a listing must contain. Each listing must give the clinician’s specialty and location with contact information. It must say whether the clinician is accepting new patients. It must also cover disability access and languages, along with telehealth capability.
The member protection matters most to patients. A member who books with a clinician listed as in network, and then learns the clinician is not, would owe no more than the in-network amount. That moves the cost of a wrong listing from the member to the plan.
The flag for unverified listings matters too. A member who sees that a listing may be out of date knows to call before driving across town. Today a stale listing looks the same as a fresh one.
What the member protection will cost plans
The cost-sharing protection is the part of the law with a price attached. Each wrong listing that sends a member out of network becomes a claim the plan pays at in-network cost sharing for the member. The plan absorbs the difference.
That changes the arithmetic of accuracy. A plan that once saw a stale listing as a minor compliance issue will now see it as a cost on every claim it causes. The cheapest way to avoid the cost is to keep the listing right. Few rules line up the plan’s money with the member’s experience so directly.
What the October proposal does
CMS proposed rules to carry out the law on October 16, 2026, according to its fact sheet. The proposal covers verification and maintenance standards and the annual accuracy analysis. It also covers public reporting of scores and the cost-sharing protections. CMS would display accuracy scores in a machine-readable format, and plans would display them prominently in their directories.
Comments are open for 60 days after the rule’s publication in the Federal Register. The proposal is a draft. CMS can change details after comments, and plans have more than a year before the verification clock starts. The same proposal carries provisions on Part D drug costs and pharmacy benefit managers that the law also required.
CMS also linked the rule to a larger project. It is building a national provider directory meant to hold directory information for insurers across the country. Data collected from Medicare Advantage plans under the proposal could ultimately feed into it, according to Healthcare Dive.
Why directories stay wrong
Directories are wrong for ordinary reasons. Clinicians change practices and add or close locations. They stop taking new patients when their panels fill. Groups add and lose members. Each change happens in a clinician’s office. The plan hears about it late, if at all.
Telehealth adds another wrinkle. A clinician who sees patients only by video may still be listed at an office address. The new law’s telehealth field should help members tell the difference.
Some errors come from how groups contract. A group may list every clinician at every one of its locations, because the contract covers them all. A member who calls a satellite office may learn that the clinician works there 1 day a month, or never.
The errors are large. A 2023 review by the staff of Senator Ron Wyden called 120 provider listings across 12 plans. A third of the listings were inaccurate or had no working number, or the calls went unreturned, according to the AMA. Callers could get an appointment only 18% of the time. More than 80% of the in-network mental health providers they tried to reach were ghosts.
A directory is a promise about access. The rules now measure whether the promise is kept.
Specialty studies find the same pattern. In a study of dermatology listings in a subset of Medicare Advantage plans, only 26.6% passed every test of a usable listing, according to the AMA. Each listing had to be unique and accept the patient’s insurance. It also had to offer an appointment.
Why mental health is worse
Several features of behavioral health practice make listings harder to keep current. Many therapists work alone or in small groups, with no staff to answer verification calls. Many work part time across more than 1 setting. Panels fill quickly, and a therapist who is full may stay listed as open for months.
Some clinicians also leave networks without telling every plan. A therapist who stops taking a plan’s patients may never send the paperwork to end the contract. The plan keeps the listing because, on paper, the clinician is still in network.
Those patterns explain why the ghosts cluster in mental health. They also explain why a 90-day call cycle alone will struggle there. The offices least able to answer the calls are the ones most likely to be wrong.
What verification costs
Verification by plans has its own cost. Every plan that contracts with a clinician must confirm the same facts on the same clock. A busy practice in 10 networks could field 40 verification requests a year under a 90-day rule. Offices that ignore the calls will be flagged as unverified, which helps no one. The burden also grows with every new plan a practice joins.
The cost falls on both sides. Plans pay staff or vendors to make the calls. Practices pay staff to answer them. The member gains only when the answer changes something, and most of the time it does not.
A rule that makes every plan verify separately multiplies that cost by the number of plans. A rule that lets a clinician confirm once, for every plan, divides it.
The source of truth problem
The facts in a directory have an owner, and it is not the plan. A clinician knows where they practice and whether they are taking patients. The plan knows only what it was told and when.
Credentialing already faces this problem with licenses and sanctions. Our piece on verifying credentials once argued that every plan should not repeat the same primary source check. Our piece on signed credentials proposed that licensing boards sign license data so any plan can check it. Directory facts need the same treatment from the clinician’s side.
A national directory could be that place. If a clinician updates a location or a panel status once, every plan could read the change within a day. A plan’s 90-day verification would become a check that the plan’s copy matches the shared record. The flag for an unverified listing would mean the clinician had not confirmed the record, not that a plan had failed to reach the office.
The shared record could draw on data clinicians already report to Medicare, such as their enrollment records. It would still need a way for clinicians to confirm whether they are taking new patients, a fact no current federal record holds.
The shared record should carry its own history. Each change should show who made it and when. A listing that a clinician confirmed last week is worth more than one a vendor scraped last year, and the record should say which is which.
Claims can find stale listings
Plans also hold a signal that directories rarely use. A clinician who is listed at a location but has billed no claims from it in 6 months is probably not there. A clinician who bills from a new address is probably practicing there. Neither fact is proof, but both are good reasons to check. The check works in reverse too. A clinician who bills from an address that no directory lists may be a network member the plan has forgotten to show.
That signal fits the way we think about other data checks. Our piece on anomaly scores argued that a data pattern should start a review rather than end one. A claims-based flag should prompt a call to the office, not remove a clinician on its own.
Who answers for shared data
A shared record raises an accountability question the final rule has to answer. If a plan relies on a national directory and the shared record is wrong, the law still holds the plan responsible for its score. Plans will want a safe harbor for data they draw from a federal source. Members will want someone to be responsible either way. The final rule should say plainly who answers for what. A workable answer is a split. A plan would answer for data it supplies or confirms. The directory’s operator would answer for changes it makes from outside sources.
What accuracy should measure
An accuracy score is only as useful as its test. A listing can be correct in every field and still useless if the clinician has no openings for 4 months. The Wyden review found appointments only 18% of the time, which is the measure a member feels.
Scores should test what a member would test. A good score would include whether a caller reached the office and whether the listed clinician was taking patients. It would also check whether an appointment was available within a reasonable time. Mental health listings deserve extra weight, because that is where the ghosts were most common.
Sampling should be random and large enough to compare plans of different sizes. A small plan’s score should not swing on a handful of calls.
The method should be public. A plan should be able to see how its sample was drawn and how each listing was scored. So should the members who rely on the score. A score that cannot be checked will be argued over rather than used.
What plans can do before 2028
Plans do not need to wait for the final rule. Most already run a public provider directory API under CMS’s earlier interoperability rule, as our piece on the 2027 payer API deadline described. The same data can serve members and Plan Finder if it is kept in 1 place. It can also serve the new verification rules.
- Join the two records. Credentialing files and directory listings often live in separate systems. A plan that links them can see when a credentialed clinician has no current listing, or a listing has no current credential.
- Date every field. Each listing field should carry the date it was last confirmed and the source of the confirmation. That is the record the 90-day rule will ask for.
- Start with mental health. The worst errors are there. A plan that cleans its behavioral health listings first will improve its score where members feel it most.
- Measure your own rate. A plan can run its own sample of calls now and learn where it stands before CMS scores it.
- Ask clinicians to confirm in bulk. A single confirmation that covers every location and every product line is easier for an office than separate calls for each.
Where Redlake stands
Redlake builds tools that health plans use in utilization review. Directories touch our work when a member needs a referral or a network exception, and a wrong listing turns into a delay. A member who cannot find an in-network clinician often ends up asking for an exception. That request lands in review because the directory failed first.
Verify at the source. Clinicians should be able to update their directory information once, in a shared record that every plan reads. Plans should verify their copy against that record rather than call the same office on separate clocks.
Make the shared record accountable. A national directory should keep a history of every change and who made it. Every decision should be possible to reconstruct, and a directory listing is a decision about what a member is told.
Use claims as a lead. Plans should compare listings with recent claims and check any listing that the claims contradict. A machine can flag a stale listing. A person should confirm it before it comes down.
Score what members experience. Accuracy scores should measure whether a member can reach the office and book a visit, not only whether the fields match.
Weight mental health. Mental health listings showed the most ghosts. Scores should sample them more heavily so plans cannot hide weak behavioral networks inside a good average.
Pay the protection without a fight. When a wrong listing sends a member out of network, the plan should apply in-network cost sharing automatically when the claim shows the listing. The member should not have to prove the listing existed.
What to watch in the rest of 2026
- Comments on the proposal. Watch the comment record for how plans and providers want accountability for shared data handled.
- The national directory. Watch for CMS’s timeline and for whether providers can update their own records in it.
- Plan Finder. Watch how directory data performs in Medicare Plan Finder during the enrollment period for 2027.
- Mental health networks. Watch whether the final rule gives behavioral health listings special weight in accuracy scoring.
- State action. Watch for state rules that apply similar standards to commercial and Medicaid plans.
- Safe harbor language. Watch whether CMS protects plans that rely on a federal directory record that turns out to be wrong.
About this analysis
Method. The REAL Health Providers Act, CMS’s October 2026 proposal to implement it and the directory rule CMS finalized in 2025 are described from CMS’s fact sheet and the AMA’s summary of the law. Trade press reporting fills in the rest.
Data notes. The Wyden review and the dermatology study are as summarized by the AMA. The example of verification requests per practice is illustrative arithmetic, not a measured figure. Details of the October proposal may change in the final rule.
Sources. CMS fact sheet on the directory and drug provisions of the 2026 appropriations law (October 16, 2026). AMA on the REAL Health Providers Act (March 11, 2026). Healthcare Dive (October 19, 2026).
Frequently asked questions
What is the new directory law?
The REAL Health Providers Act is a 2026 federal law that sets directory accuracy standards for Medicare Advantage plans. It passed as part of the 2026 appropriations law. Its main requirements begin in 2028.
How often must plans verify directory listings?
At least every 90 days for clinicians, starting in 2028. Hospitals and similar facilities must be verified at least every 12 months.
What happens if a member relies on a wrong listing?
A member who receives out-of-network care because a directory listed the clinician as in network would pay no more than in-network cost sharing.
When will directory accuracy scores be public?
Plans must display their accuracy scores starting in 2029. CMS will also publish the scores in a machine-readable format.
What is the national provider directory?
It is a central repository of provider directory information that CMS is building. Data collected under the new Medicare Advantage rules could feed into it.
How fast must plans remove clinicians who leave?
Within 5 business days of determining that the clinician no longer participates, starting in 2028.
Why are mental health listings less accurate?
Many behavioral health clinicians work alone or part time and have no staff to answer verification requests. Panels fill quickly, and listings are not always updated when they do.
Do the new rules apply to commercial plans?
The law applies to Medicare Advantage plans. Commercial and Medicaid plans follow their own federal and state rules on directories. State laws may add requirements of their own.