Even well-intentioned laws cannot protect us from the wrong supplier directory

If you have medical insurance, you’ve probably been overwhelmed at some point trying to find an available doctor or mental health practitioner in your health plan’s network.

It goes like this: You find multiple providers in your plan directory and you call them. All of them. Alas, the number is wrong; or the doctor has left, or retired, or is not accepting new patients; or the next available appointment is three months away. Or perhaps the provider is not in your network.

Despite a spate of state and federal regulations that require more accurate health plan directories, they can still contain numerous errors and are often insanely outdated.

Faulty directories not only hinder our ability to provide care but also indicate that health insurers are not meeting requirements to provide timely care — even if they tell regulators they are.

Worse, patients who rely on inaccurate directory information may face inflated bills from doctors or hospitals that are out of their network.

In 2016, California implemented a law to regulate the accuracy of provider directories. The state was trying to deal with chronic problems, illustrated by an embarrassing debacle in 2014, when Covered California, the insurance marketplace the state created after the passage of the Affordable Care Act, was forced to pull its flawed directory. First year.

Also in 2016, the federal Centers for Medicare and Medicaid Services called for a more accurate directory of Medicare Advantage health plans and policies sold through the federal ACA Marketplace. And the federal No Surprises Act, which went into effect this year, extends similar rules to employer-based and individual health plans.

California law and the federal No Surprises Act stipulate that patients who rely on their provider directory information and unknowingly see doctors outside their network must not pay more than they would for an in-network provider.

Unfortunately, misinformation continues to plague our healthcare system.

A study published in June in the journal Health Politics, Policy & Law analyzed data from the California Department of Managed Health Care on guideline accuracy and timely access to care. It found that at best, consumers can get timely appointments in emergencies 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 and pro-consumer laws and regulations have effectively failed to provide sufficient protection for consumers.”

Few people know this better than Dan O’Neill. A San Francisco health care executive called local primary care doctors listed in her health plan directory through a major national carrier and could not get an appointment. He could not say whether UCSF Health, one of the city’s major health systems, is in its network with whom he spoke.

“I spent about a week trying to get this problem resolved and finally had to give up and pay the $75 copay to go to urgent care because that was the only option,” O’Neill said. “I’m now a seven- or eight-minute walk from the main UCSF building, and to this day, I have no idea if they’re in my network, which is crazy because I do this professionally.”

Consumer health advocates say insurers aren’t taking directory accuracy seriously. “We have health plans with millions of enrollees and tens of millions in reserves,” said Beth Capel, a lobbyist for Sacramento-based Health Access California. “These people have the resources to do it if they felt 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 must constantly hound them to send updates. Are they still with the same practice? Same address? Accepting new patients?

For doctors and other practitioners, responding to such surveys — sometimes from dozens of health plans — isn’t at the top of their to-do list. Insurers typically offer multiple health plans, each with a different provider star, so people don’t always know which one they’re on.

The law offers some benefits to insurers to prompt providers to respond, and an entire industry has developed around collecting provider updates through a centralized portal and selling the information to health plans. However the error problem remains. Health plans and providers often have outdated data systems that don’t communicate with each other.

A significant improvement in health plan directories “will require more connectivity and interoperability,” said Simon Hyder, an associate professor at Texas A&M University’s School of Public Health and co-author of the study on directory accuracy and timely access.

Until that day comes, you have to fend for yourself. Be diligent when using your health plan provider directory. You should use this as your first stop — or to check if there’s a doctor recommended by a friend in your network.

Remember the laws that say you can’t be charged out-of-network rates if the doctor you see is listed in your health plan’s directory? You have to prove that was the case. So take a screenshot of the directory showing the provider name and save it. Then, call the doctor’s office to double check. Take notes and get the name of the person you spoke with. Also call your health plan if there is a discrepancy.

If you find an incorrect entry, report it to your health plan. California law requires plans to provide instructions to consumers to do this. 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 department (888-466-2219 or www.healthhelp.ca.gov). Since California’s provider directory law went into effect, the department has helped resolve 279 complaints, spokeswoman Rachel Arezola said.

If your plan has a different regulator, the department can point you in the right direction.

If you are one of the nearly 6 million Californians in a federally regulated employer or union plan and you receive a large out-of-network bill from a doctor listed in your health plan directory, you can file an appeal through Office Sett for that 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 of health care costs and easier access to patient records. All of that would require a more open information superhighway.

This story was produced by KHN, which publishes California Healthline, the editorially independent service of the California Health Care Foundation.

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