If you have health insurance, chances are you’ve been completely pissed off at some point while trying to find a doctor or mental health practitioner available in your health plan network.
It’s like this: you find multiple providers in your plan directory and call them. All of them. Alas, the number is wrong; or the doctor has moved, retired, or is not accepting new patients; or the next available appointment is three months away. Alternatively, the provider might not be in your network at all.
While there are a plethora of state and federal regulations requiring more accurate catalogs of health plans, they can still contain many errors and are often maddeningly out of date.
Flawed listings not only hinder our ability to access care, but also show that health insurers are not meeting the requirements to provide timely care — even when they tell regulators they are.
To make matters worse, patients who rely on incorrect directory information may end up facing inflated bills from doctors or hospitals that go beyond their network.
In 2016, the state of California implemented a law to regulate the accuracy of the catalog of providers. The state is trying to fix a long-standing problem, as illustrated by an embarrassing 2014 debacle when Covered California, the state’s insurance marketplace created after the passage of the Affordable Care Act, was forced to include its erroneous catalogue included in its first year.
Also in 2016, the Centers for Medicare and Medicaid Services requested a more accurate catalog of Medicare Advantage health plans and policies sold through the federal ACA marketplace. The federal No Surprise Act, which took effect this year, extends similar rules to employer- and individual-based health plans.
California law and the federal No Surprise Act require patients who rely on information to pay more than they do for in-network physicians who cannot ask for their provider directory and end up inadvertently seeing their out-of-network physicians Fees paid by the provider.
Unfortunately, inaccurate catalogs continue to plague our healthcare system.
June Published in the Journal of Health Politics, Policy and Law A study analyzed data from the California Department of Managed Healthcare on catalog accuracy and timely access to care. It found that in the best-case scenario, consumers can make timely appointments in emergencies, while only 54% of doctors are listed in the directory. Worst case: 28%. For general care appointments, the best-case scenario was 64% and the worst-case scenario was 35%.
A key conclusion, the authors write, is that “even progressive and consumer-friendly legislation and regulations have actually failed to provide substantial consumer protection.”
Few people know this better than Dan O’Neill. The San Francisco healthcare executive called a local primary care physician listed in his health plan directory through a major national carrier, but was unable to make an appointment. No one with whom he spoke could tell him whether UCSF Health was in his network.
“I spent almost a week trying to figure this out and ended up having to give up and pay the $75 copay to go to urgent care because it was the only option,” O’Neal said. “Where I live now is a 7 or 8 minute walk from the main UCSF buildings and to this day I don’t know if they are in my network or not, which is crazy because I do it professionally. “
Consumer health advocates say insurers don’t take catalog accuracy seriously. “We have health plans with millions of enrollees and hundreds of millions in reserves,” said Beth Capel, a lobbyist for the Sacramento-based California Health Channel. “If these people think it’s a priority, they have the resources to do it.”
Industry analysts and academic researchers say it’s more complicated than that.
Health plans contract with thousands of providers and must constantly hunt them down to send updates. Are they still doing the same thing? at the same address? Accept new patients?
For physicians and other practitioners, responding to such surveys—sometimes from dozens of health plans—is hardly a priority. Insurance companies often offer multiple health plans, each with a different set of providers, and they don’t always know which plans they’re in. Entire industries have sprung up around collecting provider updates through centralized portals and selling the information to health plans. However, the problem of inaccuracy remains. Health plans and providers often have outdated data systems that don’t communicate with each other.
Significant improvements to the health plan catalog will require “more connectivity and interoperability,” said Simon Hyde, associate professor at Texas A&M University’s School of Public Health and is about Co-author of a study for catalog accuracy and timely access.
Until that day comes, you need to fend for yourself. Be diligent when using your health plan’s provider directory. You should make this your first stop – or check to see if a doctor recommended by a friend is in your network.
Remember the law says you cannot be billed out-of-network if the doctor you visit is listed on your health plan directory? You have to prove this is the case. So take a screenshot of the directory showing the provider name and save it. Then, call your doctor’s office for a careful examination. Take notes and write down the names of the people you are talking to. Also call your health plan if there are differences.
If you find an entry inaccurate, please report it to your health plan. California law requires plans to provide instructions to consumers. If you enroll in a commercial health plan, your policy may be regulated by the Department of Managed Health Care. You can file a complaint through the department (888-466-2219 or www.healthhelp.ca.gov). The department has helped resolve 279 complaints since California’s provider directory law went into effect, said spokeswoman Rachel Arrezola.
If your plan has a different regulator, this department 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 you receive a large payment from a doctor listed on your health plan directory Out-of-network bills, you can appeal through the office established 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 push for greater transparency in healthcare pricing and easier access to patient records. All of this requires a more open information superhighway.
This story was produced by KHN, which publishes California Healthline, an independent editorial service of the California Healthcare Foundation.