Directories of health insurance providers often contain errors. what to do, a health consumer guide
If you have medical insurance, chances are you’ll be exasperated at some point trying to find a doctor or mental health practitioner available within your health plan’s network.
You find several providers in your plan directory and call them. All. But the number is wrong. Or the doctor has moved or retired or is not accepting new patients. Or the next available appointment is in three months. Or the provider is not actually in your network.
Despite state and federal regulations requiring more accurate health plan directories, they can still contain errors and are often out of date.
Faulty directories don’t just hamper our ability to get care. They also report that health insurers are failing to meet requirements to provide timely care, even as they tell regulators.
Worse, patients who rely on faulty directory information may face inflated bills from doctors or hospitals that turn out to be outside their network.
In 2016, California implemented a law to regulate the accuracy of provider directories. The state was trying to fix longstanding problems, exemplified by an embarrassing debacle in 2014, when Covered California, the insurance market the state formed after the Affordable Care Act passed, was forced to withdraw his error-ridden repertoire in his first year.
Also in 2016, the federal Centers for Medicare & Medicaid Services demanded more accurate directories for Medicare Advantage health plans and policies sold in the federal ACA market. The federal No Surprises Act, which took effect this year, extends similar rules to employer and individual health plans.
The No Surprises Act states that patients who rely on information in their provider directories and end up unknowingly seeing physicians outside of their networks cannot be required to pay more than they would have paid for a network provider.
Unfortunately, inaccurate directories continue to plague the health care system.
A study published in June in the Journal of Health Politics, Policy and Law analyzed data from the California Department of Managed Health Care on the accuracy of directories and timely access to care. It found that, at best, consumers were able to get timely appointments for urgent cases with only 54% of doctors listed in a directory. Worst case: 28%. For general care appointments, the best case was 64% and the worst case was 35%.
A key takeaway, the authors write, is that “even progressive, pro-consumer laws and regulations have effectively failed to offer substantial consumer protection.”
Few know this better than Dan O’Neill. The San Francisco health care official called the primary care physicians listed in his health plan’s directory, through a major national carrier, and was unable to get an appointment. No one he spoke to could tell him if UCSF Health, one of the city’s major health systems, was part of his network.
“I spent almost a week trying to sort this out and eventually had to give up and pay the $75 copayment to go to emergency care because it was the only option,” says O’Neill. “I now live a seven or eight minute walk from the main buildings at UCSF and to this day have no idea if they are part of my network or not, which is crazy because I do it professionally.”
Consumer health advocates say insurers don’t take the accuracy of directories seriously.
“We have health plans with millions enrolled and hundreds of millions on reserve,” says Beth Capell, lobbyist for Health Access California. “These people have the resources to do it if they thought it was a priority.”
Industry analysts and academic researchers say it’s more complicated than that.
Health plans contract with hundreds of thousands of providers and have to track them down to send updates. Are they still with the same practice? At the same address? Accepting new patients?
For doctors and other practitioners, answering such surveys — sometimes from dozens of health plans — is hardly at the top of their to-do list. Insurers typically offer multiple health plans, each with a different constellation of providers, who may not always know which ones they are in.
The law gives insurers some leverage to get providers to respond, and an industry has sprung up around collecting updates from providers through a centralized portal and selling the information to health plans. Yet health plans and providers often have outdated data systems that don’t communicate with each other.
Significantly improving health plan directories will require “more connectivity and interoperability,” says Simon Haeder of Texas A&M University’s School of Public Health, co-author of the Accuracy Study. directories and quick access.
Until that happens, you have to fend for yourself. Use your health plan’s provider directory as a first stop or to check if a doctor recommended by a friend is in your network.
Remember the laws that say you can’t be charged out-of-network rates if the doctor you’re seeing was listed in your health plan directory? You will have to prove that it was. So take a screenshot of the directory showing the provider name and save it.
Call the doctor’s office to check. To take notes. Get the name of the person you spoke to. If there is a discrepancy or you find an inaccurate entry, report it to your health insurance plan.
KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism on health issues.