Provider Directories Can Be Wrong: The Doctor-Check Step Every AEP Appointment Needs
Because MA provider directories can list doctors who aren't actually seeing plan members, agents should confirm each client's key doctors directly with the office before enrolling them in a Medicare Advantage plan.
Quick answer:
Treat the directory as a starting point. Federal reviews keep finding listings that are out of date.
Verify what matters most. Primary care, active specialists, preferred hospitals and ongoing treatment.
Ask about the exact plan. New or existing patients, that plan, that location, next plan year.
Write it down. Date, office, staff name and the answer, in your CRM.
Never promise access. Networks can change during the year.
This is one step inside my AEP 2027 playbook for Medicare agents. It's a five-minute habit that protects your client, your book and your name.
What MedPAC found about MA directories (October 2026)
At its October 8, 2026 public meeting, MedPAC staff compared MA provider directories with MA encounter data, the records of who actually delivered care (MedPAC October 2026 presentation). The slides are marked preliminary, with more work planned for MedPAC's June 2027 report. Using 2023 data, staff reported:
Over 95% of Medicare physicians provided care to MA enrollees in 2023, based on encounter data.
Nearly 10% of physicians weren't in any MA provider directory, even though MA made up more than 5% of their Medicare claims volume.
In February 2023, 32% of MA encounters had a rendering physician who wasn't listed in the enrollee's own plan directory.
MedPAC was careful with that last number. It could mean the directory was incomplete, lagged or inaccurate, or that the physician was out of network at the time. Staff also described the directory system as complex, "with documented inaccuracies," and noted that networks can change throughout the plan year.
Older federal reviews point the same way. CMS's third round of online directory reviews found 48.74% of provider locations checked had at least one inaccuracy, including providers not accepting new patients when the directory said they were (CMS, 2018). In October 2025, the HHS Office of Inspector General reported that, on average, 55% of behavioral health providers listed in the MA networks it studied didn't provide a single service to enrollees in 2023 (OIG, 2025).
This isn't a knock on any one plan. Plans must already update online directories within 30 days of receiving new information (42 CFR 422.2267(e)(11)) and keep a complete, accurate public directory API on the same 30-day clock (42 CFR 422.120). But doctors move, retire and change jobs, and they have to update every plan they contract with. I covered CMS's newer proposal in CMS's proposed ghost network rule. This post is about the appointment.
Why directory errors become your problem
Your client won't remember the directory. They'll remember you.
If a client picks a plan because their doctor is "in it" and then the office won't see them, that's a disruption for them, a service call for you and a dent in the trust you've built. Trust compounds. So does the damage when it breaks.
Networks also change after enrollment. When a contracted provider leaves, the plan must notify affected enrollees at least 45 calendar days ahead for primary care and behavioral health, and at least 30 days ahead for other specialties (42 CFR 422.111(e)). A network change is not the same as losing the plan, and I walked through those calls in how to handle hospital contract disputes.
You can't control a contract. You can control whether you checked.
A 5-minute doctor-verification routine
Which providers to verify
At minimum:
Primary care provider. The relationship most clients care about most.
Every active specialist. Anyone they've seen recently or have an appointment coming up with.
Preferred hospitals. Where they'd want to go if something happens.
Ongoing treatment. Dialysis, infusion, cancer care and behavioral health. MedPAC noted behavioral health providers are less likely to participate in networks across all payers, and OIG found many inactive listings there.
Start with the plan's directory. As of plan year 2026, some MA network information is also on Medicare Plan Finder, per the MedPAC presentation. Then pick up the phone.
What to ask the office
Best case, the client is on the line with you. If not, call with their permission. Ask for whoever handles insurance and keep it short:
"Hi, this is [your name]. I'm a licensed insurance agent helping one of your patients review Medicare coverage for next year. Can you confirm whether Dr. [name] is accepting [new or existing] patients on [exact plan name and plan type] at this location for the 2027 plan year? Do you know of any expected changes with that plan? And may I get your name for my notes?"
Three details matter:
The exact plan, not just the carrier. "We take that company" doesn't tell you whether they take that HMO.
New versus existing patients. An office can keep current patients on a plan and not take new ones.
The new plan year. Next year's contracts may not be settled. "I don't know" is an answer. Write it down.
How to document it
Log it in your CRM before you move on: date and time, office name and number, staff name, the exact plan you asked about and the answer in their words. Add what you told the client.
That note protects the client and you. It shows what was confirmed, and that you did the work. Keep it alongside your scope of appointment and call records. If you're a Brock partner, GoGuruX includes compliance documentation for exactly this kind of note.
Then tell the client: "As of today, Dr. [name]'s office says they're seeing existing patients on this plan. Networks can change, so if you get a letter about your doctor, call me." That's honest. It's not a promise.
When the network doesn't fit: options to review
Sometimes the doctor isn't in. That's not a dead end. It's a conversation. Lay out the tradeoffs and let the client decide:
Another MA plan that includes their doctors. Run the same check again.
A plan with out-of-network coverage. Medicare.gov notes some MA plans cover non-emergency care out of network, but it may cost more. MedPAC's out-of-network table shows an HMO enrollee who chooses to go out of network can owe the full bill, while a PPO usually charges higher cost sharing.
Original Medicare with a Medigap policy. Any doctor who takes Medicare. But outside the Medigap open enrollment period or a guaranteed issue right, the insurer can deny coverage based on medical underwriting (Medicare.gov). Underwrite first and never drop coverage before approval. If the plan is leaving the area, see MA plan exits and guaranteed issue Medigap.
Stay put. If the current plan still fits their doctors, no change may be the right call.
If more of your clients are landing in HMOs, this step matters even more (margin over membership).
Building verification into your AEP workflow
The habit only works if it lives in your process, not your memory.
At booking. Collect doctors, hospitals and pharmacies with the medication list, including locations and phone numbers.
Before the appointment. Verify the primary care doctor and top specialists against the plans you expect to compare.
During the appointment. Confirm the list is complete and recheck anything you couldn't reach.
Before you submit. Make sure the verification note for the chosen plan is in the CRM.
After the plan starts. Call to ask how the first appointment went.
Offices are slammed in the fall. Batch your calls, keep the script tight and be kind to the front desk.
FAQs
Is the plan's provider directory reliable?
Directories can be out of date, so treat them as a starting point and confirm with the provider's office. CMS and OIG reviews have found listings for providers who weren't at the address, weren't taking new patients or weren't seeing plan members.
Which doctors should I verify?
Primary care, any active specialists and preferred hospitals at minimum, plus anywhere the client gets ongoing treatment.
Should I document the verification?
Yes. Note the date, office and person you spoke with in your CRM, plus the exact plan and the answer. It protects your client and you.
Can I tell a client their doctor will stay in network all year?
No. Contracts can change during the year. Tell the client what the office confirmed and when, and ask them to call you if they get a notice.
The Bottom Line
The directory is where the check starts. It isn't where it ends.
Verify the doctors that matter. Ask about the exact plan. Write it down. Never promise what you can't control.
Want to tighten up your AEP appointment flow? Join one of our weekly live sessions, or book a call and we'll walk through it with you.
