Medical health insurance provider directories often have errors; what to do, a health consumer guide


If you’ve got medical insurance, chances are high you’ve develop into exasperated in some unspecified time in the future trying to seek out an available doctor or mental health practitioner in your health plan’s network.

You discover multiple providers in your plan’s directory, and also you call them. All of them. However the number is incorrect. Or the doctor has moved or retired or isn’t accepting latest patients. Or the following available appointment is three months away. Or the provider isn’t actually in your network.

Despite state and federal regulations that require more accurate health plan directories, they still can contain errors and infrequently are outdated.

Flawed directories not only impede our ability to get care. Additionally they signal that health insurers aren’t meeting requirements to supply timely care — even in the event that they tell regulators they’re.

Worse, patients who depend on erroneous directory information can face inflated bills from doctors or hospitals that transform outside their network.

In 2016, California implemented a law to control the accuracy of provider directories. The state was trying to handle long-standing problems, illustrated by an embarrassing debacle in 2014, when Covered California, the insurance marketplace the state formed after the passage of the Reasonably priced Care Act, was forced to drag its error-riddled directory inside its first yr.

Also in 2016, the federal Centers for Medicare & Medicaid Services demanded more accurate directories for Medicare Advantage health plans and policies sold through the federal ACA marketplace. The federal No Surprises Act, which took effect this yr, extends similar rules to employer-based and individual health plans.

The No Surprises Act stipulates that patients who depend on information of their provider directories and find yourself unwittingly seeing doctors outside their networks can’t be required to pay greater than they’d have paid for an in-network provider.

Unfortunately, inaccurate directories proceed to plague the health care system.

A study published in June within the Journal of Health Politics, Policy and Law analyzed data from the California Department of Managed Health Care on directory accuracy and timely access to care. It found that, in the very best case, consumers could get timely appointments in urgent cases with just 54% of the doctors listed in a directory. Within the worst case: 28%. For general care appointments, the very best case was 64% and the worst case 35%.

A key takeaway, the authors wrote, is that “even progressive and pro-consumer laws and regulations have effectively didn’t offer substantial protection for consumers.”

Few know this higher than Dan O’Neill. The San Francisco health care executive called primary care doctors listed within the directory of his health plan, through a significant national carrier, and couldn’t get an appointment. No person he talked to could tell him whether UCSF Health, considered one of the town’s premier health systems, was in his network.

“I spent near every week trying to unravel this problem and eventually had to provide up and pay the $75 copay to go to urgent care since it was the one option,” O’Neill says. “I now live a seven- or eight-minute walk from the most important UCSF buildings, and, to this present day, I do not know whether or not they are in my network or not, which is crazy because I do that professionally.”

Consumer health advocates say insurers aren’t taking directory accuracy seriously.

“Now we have health plans with thousands and thousands of enrollees and a whole lot of thousands and thousands in reserves,” says Beth Capell, a lobbyist for Health Access California. “These people have the resources to do that in the event that they thought it was a priority.”

Industry analysts and academic researchers say it’s more complicated than that.

Health plans contract with a whole lot of 1000’s of providers and must hound them to send updates. Are they still with the identical practice? At the identical address? Accepting latest patients?

For doctors and other practitioners, responding to such surveys — sometimes from dozens of health plans — is hardly at the highest of their to-do list. Insurers typically offer multiple health plans, each with a unique constellation of providers, who don’t at all times know which of them they’re in.

The law gives insurers some leverage to induce providers to reply, and an industry has sprung up around collecting provider updates through a centralized portal and selling the knowledge to health plans. Yet health plans and providers often have outdated data systems that don’t communicate with one another.

A major improvement in health plan directories would require “more connectivity and interoperability,” says Simon Haeder of Texas A&M University’s School of Public Health, a co-author of the study on directory accuracy and timely access.

Until that happens, it’s good to fend for yourself. Use your health plan’s provider directory as your first stop or to examine whether a health care provider really useful by a friend is in your network.

Remember the laws that say you’ll be able to’t be charged out-of-network rates if the doctor you visit was listed in your health plan’s directory? You’ll should prove that was the case. So take a screenshot of the directory showing the provider’s name — and reserve it.

Call the doctor’s office to double-check. Take notes. Get the name of the person you talked to. If there’s a discrepancy or you discover an inaccurate entry, report it to your health plan.

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism on health issues.


Please enter your comment!
Please enter your name here