Even well-meaning laws cannot protect us from inaccurate supplier directories
If you have medical insurance, chances are you’ve been completely exasperated at some point trying to find a doctor or mental health practitioner available within your health plan’s network.
This happens as follows: you find several providers in your plan’s directory and call them. All. Alas, the number is wrong; or the physician has moved, retired, or is not accepting new patients; or the next available appointment is in three months. Or maybe the provider just isn’t in your network.
Despite a series of state and federal regulations that require more accurate health plan directories, they can still contain many errors and are often out of date.
Faulty directories not only hinder our ability to obtain care, but also signal that health insurers are failing to meet requirements to provide timely care, even if they tell regulators.
Worse, patients who rely on faulty directory information may find themselves facing 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 freshman 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. And the federal No Surprises Act, which took effect this year, extends similar rules to employer and individual health plans.
California law and the federal No Surprises Act state that patients who rely on information in their provider directories and end up unknowingly seeing doctors outside of their networks cannot be required to pay more than that. that they would have paid for an in-network provider.
Unfortunately, inaccurate directories continue to plague our 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 people know this better than Dan O’Neill. The San Francisco health care official called local 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 I have no idea if they’re part of my network or not, which is crazy because I do it in a professional way.”
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 Sacramento-based 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 constantly have to pester them 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 entire industry has sprung up around collecting updates from providers through a centralized portal and selling the information to health plans. The problem of vagueness remains, however. Healthcare 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, associate professor at Texas A&M University’s School of Public Health and co-author of the Directory Accuracy Study and quick access.
Until that day comes, you will have to fend for yourself. Be diligent when using your health plan’s provider directory. You should use it 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. Then call the doctor’s office to check. Take notes and get the name of the person you spoke to. If there is a discrepancy, call your health plan as well.
If you find an inaccurate entry, report it to your health plan. California law requires plans to provide instructions for consumers to do so. If you’re in a commercial health plan, your policy is likely regulated by the Department of Managed Health Care. You can file a complaint with the ministry (888-466-2219 or www.healthhelp.ca.gov). Since California’s provider directory law took effect, the department has helped resolve 279 complaints, spokeswoman Rachel Arrezola said.
If your plan has a different regulatory body, the ministry can point you in the right direction.
If you are one of approximately 6 million Californians in a federally regulated employer or union plan and receive a large out-of-network bill from a doctor that was listed in your health plan directory, you can lodge an appeal via the office. for this purpose (800-985-3059 or www.cms.gov/nosurprises).
Ultimately, efforts to improve the accuracy of provider directories are part of a broader campaign for greater transparency in healthcare pricing and easier access. to patient records. All of this will require a more open information highway.
KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism on health issues. Along with policy analysis and polls, KHN is one of the three main operating programs of the KFF (Kaiser Family Foundation). KFF is an endowed non-profit organization providing information on health issues to the nation.
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