Lists of health insurance providers often contain errors; what to do, a guide for the health consumer

If you have medical insurance, chances are you got exasperated at some point trying to find a doctor or mental health professional available in your health plan network.

You find multiple providers in your plan directory and call them. All of them. 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 isn’t actually in your network.

Despite state and federal regulations requiring more accurate health plan lists, they can still contain errors and are often out of date.

Faulty directories not only impede our ability to receive assistance. They also report that health insurers do not meet the requirements to provide timely care, even as they tell regulators that they are.

Worse still, patients who rely on incorrect 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 address long-standing problems, illustrated by an embarrassing debacle in 2014, when Covered California, the insurance market the state formed after the Affordable Care Act passed, was forced to retire its directory. full of mistakes within its first year.

Also in 2016, the Centers for Medicare & Medicaid Services requested more accurate listings for Medicare Advantage health plans and policies sold through the federal ACA market. The federal law on surprises, which went into effect this year, extends similar rules to individual and employer-based health plans.

The No Surprises Act states that patients who rely on information in their providers’ directories and end up unknowingly seeing doctors outside their networks cannot be required to pay more than they would have paid for an online provider.

Unfortunately, inaccurate lists continue to plague the healthcare 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 directory accuracy and timely access to care. It found that, at best, consumers could get timely appointments in urgent cases with only 54% of doctors listed on a list. In the worst case: 28%. For general care appointments, the best case was 64% and the worst case was 35%.

A key point, the authors write, is that “even progressive and consumer-friendly legislation and regulations have failed to offer substantial consumer protection.”

Few know this better than Dan O’Neill. The San Francisco health care executive called the GPs listed on his health plan list, via 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 major health systems in the city, was in his network of him.

“I spent nearly a week trying to fix this and eventually had to give up and pay $ 75 to go to urgent care because it was the only option,” O’Neill says. “I now live seven or eight minutes’ walk from the main UCSF buildings and, to this day, I have no idea if they are in my network or not, which is crazy because I do it professionally.”

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

“We have health plans with millions of subscribers and hundreds of millions in reserves,” says Beth Capell, a Health Access California lobbyist. “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 stalk them to send updates. Am I still with the same practice? At the same address? Accepting new patients?

For doctors and other professionals, 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 don’t always know which ones they are on.

The law gives insurers some leverage to get suppliers to respond, and an industry has sprung up around collecting supplier updates through a centralized portal and selling information to health plans. However, health plans and providers often have outdated data systems that don’t communicate with each other.

Significant improvement in health plan directories will require “greater connectivity and interoperability,” says Simon Haeder of Texas A&M University School of Public Health, co-author of the study on directory accuracy and timely access.

Until that happens, you need to look after yourself. Use your health plan provider list as a first stop or to check if a friend recommended doctor is in your network.

Remember the laws that say offline rates cannot be charged if the doctor you see was listed in your health plan directory? You will have to prove that this was the case. Then take a screenshot of the directory showing the provider name and save it.

Call the doctor’s office for a double check. Take note. 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 plan.

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

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