Health insurance provider directories often have errors; what to do healthy user guide

If you have medical insurance, chances are you’ve gotten frustrated at some point trying to find an available doctor or mental health specialist in your health plan’s network.

You find multiple providers in your plan directory and call them. All of them. But the number is wrong. Either the doctor has moved or retired or is not taking new patients. Or the next available appointment is in three months. Or the provider is not actually in your network.

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and federal regulations requiring more accurate health plan directories, they can still contain errors and are often out of date.

Incorrect pointers not only hinder our ability to receive care. They also signal that health insurance companies are not complying with requirements to provide timely care – even if they tell regulators they are.

Worse, patients who rely on wrong information from the directory can face inflated bills from doctors or hospitals that happen to be out of their network.

In 2016, California enacted a law to regulate the accuracy of provider directories. The state has been trying to address longstanding problems, illustrated by an embarrassing failure in 2014 when Covered California, the insurance marketplace the state formed after the Affordable Care Act was passed, was forced to withdraw its error-ridden directory within the first you are a year

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

The No Surprises Act states that patients who rely on information in their provider directories and end up unwittingly seeing doctors outside their networks cannot be required to pay more than they would for an in-network provider.

Unfortunately, inaccurate pointers 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, users could only get timely emergency appointments with 54% of doctors listed in a directory. At worst: 28%. For general care appointments, the best case is 64% and the worst case is 35%.

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

Few know this better than Dan O’Neill. The San Francisco health care executive called primary care doctors listed in his health plan’s directory through a major national carrier and couldn’t get an appointment. No one he spoke to could tell him if UCSF Health, one of the city’s leading health systems, was in his network.

“I spent nearly a week trying to get this problem resolved, and I ended up having to give up and pay $75 to go to the ER because that was the only option,” O’Neill says. “Now I live a seven- or eight-minute walk from the main buildings at UCSF, and to this day I have no idea if they’re on my network or not, which is crazy because I do this professionally.”

Consumer health advocates say insurers don’t take the accuracy of pointers seriously.

“We have health plans with millions enrolled and hundreds of millions in reserves,” said Beth Capel, a lobbyist for Health Access California. “These people have the resources to do that if they think it’s 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 track them down to send updates. Are they still the same practice? At the same address? Accepting new patients?

For doctors and other practitioners, responding to 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 who they’re with.

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

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

Until that happens, you have to fend for yourself. Use your health plan’s provider directory as a first stop or to check if a doctor referred by a friend is in your network.

Remember the laws that said you couldn’t be charged out-of-network rates if the doctor you were seeing was listed on your health plan’s directory? You will have to prove that this is so. So take a screenshot of the directory showing the provider name — and save it.

Call the doctor’s office to double check. I’m taking notes. Get the name of the person you spoke with. If there is a discrepancy or you find an inaccurate record, report it to your health plan.

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

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