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If you have medical insurance, chances are you\u2019ve been utterly exasperated at some point while trying to find an available doctor or mental health practitioner in your health plan\u2019s network.<\/p>\n
It goes like this: You find multiple providers in your plan\u2019s directory, and you call them. All of them. Alas, the number is wrong; or the doctor has moved, or retired, or isn\u2019t accepting new patients; or the next available appointment is three months away. Or perhaps the provider simply is not in your network.<\/p>\n
Despite a spate of state and federal regulations that require more accurate health plan directories, they can still contain numerous errors and are often maddeningly outdated.<\/p>\n
Flawed directories not only impede our ability to get care but also signal that health insurers aren\u2019t meeting requirements to provide timely care \u2014 even if they tell regulators they are.<\/p>\n
Worse, patients who rely on erroneous directory information can end up facing inflated bills from doctors or hospitals that turn out to be outside their network.<\/p>\n
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 marketplace that the state formed after the passage of the Affordable Care Act, was forced to pull its error-riddled directory within its first year.<\/p>\n
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. And the federal No Surprises Act, which took effect this year, extends similar rules to employer-based and individual health plans.<\/p>\n
California law and the federal No Surprises Act stipulate 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 have paid for an in-network provider.<\/p>\n
Unfortunately, inaccurate directories continue to plague our health care system.<\/p>\n
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 in the best case, consumers could get timely appointments in urgent cases with just 54% of the doctors listed in a directory. In the worst case: 28%. For general care appointments, the best case was 64% and the worst case 35%.<\/p>\n
A key takeaway, the authors write, is that \u201ceven progressive and pro-consumer legislation and regulations have effectively failed to offer substantial protection for consumers.\u201d<\/p>\n
Few people know this better than Dan O\u2019Neill. The San Francisco health care executive called local primary care doctors listed in the directory of his health plan, through a major national carrier, and could not get an appointment. Nobody he talked to could tell him whether UCSF Health, one of the city\u2019s premier health systems, was in his network.<\/p>\n
\u201cI spent close to a week trying to solve this problem and eventually had to give up and pay the $75 copay to go to urgent care because it was the only option,\u201d O\u2019Neill says. \u201cI now live a seven- or eight-minute walk from the main UCSF buildings, and to this day, I have no idea whether they are in my network or not, which is crazy because I do this professionally.\u201d<\/p>\n
Consumer health advocates say insurers are not taking directory accuracy seriously. \u201cWe have health plans with millions of enrollees and hundreds of millions in reserves,\u201d says Beth Capell, a lobbyist for Sacramento-based Health Access California. \u201cThese people have the resources to do this if they thought it was a priority.\u201d<\/p>\n
Industry analysts and academic researchers say it\u2019s more complicated than that.<\/p>\n
Health plans contract with hundreds of thousands of providers and must constantly hound them to send updates. Are they still with the same practice? At the same address? Accepting new patients?<\/p>\n
For doctors and other practitioners, responding to such surveys \u2014 sometimes from dozens of health plans \u2014 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\u2019t always know which ones they\u2019re in.<\/p>\n
The law gives insurers some leverage to induce providers to respond, and a whole industry has sprung up around collecting provider updates through a centralized portal and selling the information to health plans. The inaccuracy problem remains, however. Health plans and providers often have outdated data systems that don\u2019t communicate with each other.<\/p>\n
A significant improvement in health plan directories will require \u201cmore connectivity and interoperability,\u201d says Simon Haeder, an associate professor at Texas A&M University\u2019s School of Public Health and a co-author of the study on directory accuracy and timely access.<\/p>\n
Until that day comes, you will need to fend for yourself. Be diligent when using your health plan\u2019s provider directory. You should use it as your first stop \u2014 or to check whether a doctor recommended by a friend is in your network.<\/p>\n
Remember the laws that say you can\u2019t be charged out-of-network rates if the doctor you visit was listed in your health plan\u2019s directory? You\u2019ll have to prove that was the case. So take a screenshot of the directory showing the provider\u2019s name and save it. Then, call the doctor\u2019s office to double-check. Take notes and get the name of the person you talked to. If there\u2019s a discrepancy, call your health plan, too.<\/p>\n
If you find an inaccurate entry, report it to your health plan. California law requires plans to provide instructions for consumers to do that. If you are in a commercial health plan, your policy is likely regulated by the Department of Managed Health Care. You can lodge a complaint through the department (888-466-2219 or www.healthhelp.ca.gov). Since California\u2019s law on provider directories took effect, the department has helped resolve 279 complaints, said spokesperson Rachel Arrezola.<\/p>\n
If your plan has a different regulator, the department can point you in the right direction.<\/p>\n
If you are one of the roughly 6 million Californians in a federally regulated employer or union plan and you get a big out-of-network bill from a doctor who was listed in your health plan directory, you can file an appeal through the office set up for that purpose (800-985-3059 or www.cms.gov\/nosurprises).<\/p>\n
Ultimately, efforts to improve the accuracy of provider directories are part of a broader push for greater transparency of health care prices and easier access to patient records. All of that will require a more open information superhighway.<\/p>\n
This story was produced by KHN, which publishes California Healthline, an editorially independent service of the California Health Care Foundation.<\/em><\/p>\n KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.<\/p>\n This story can be republished for free (details).<\/p>\n<\/div>\n\n","protected":false},"excerpt":{"rendered":" Bernard J. Wolfson If you have medical insurance, chances are you\u2019ve been utterly exasperated at some point while trying to find an available doctor or mental health practitioner in your health plan\u2019s network. It goes like this: You find multiple providers in your plan\u2019s directory, and you call them. All of them. Alas, the number<\/p>\n","protected":false},"author":1,"featured_media":6537,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[4],"tags":[],"class_list":{"0":"post-6536","1":"post","2":"type-post","3":"status-publish","4":"format-standard","5":"has-post-thumbnail","7":"category-healthy"},"_links":{"self":[{"href":"https:\/\/www.healthoptibody.com\/index.php?rest_route=\/wp\/v2\/posts\/6536","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.healthoptibody.com\/index.php?rest_route=\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/www.healthoptibody.com\/index.php?rest_route=\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/www.healthoptibody.com\/index.php?rest_route=\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/www.healthoptibody.com\/index.php?rest_route=%2Fwp%2Fv2%2Fcomments&post=6536"}],"version-history":[{"count":0,"href":"https:\/\/www.healthoptibody.com\/index.php?rest_route=\/wp\/v2\/posts\/6536\/revisions"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/www.healthoptibody.com\/index.php?rest_route=\/wp\/v2\/media\/6537"}],"wp:attachment":[{"href":"https:\/\/www.healthoptibody.com\/index.php?rest_route=%2Fwp%2Fv2%2Fmedia&parent=6536"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/www.healthoptibody.com\/index.php?rest_route=%2Fwp%2Fv2%2Fcategories&post=6536"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/www.healthoptibody.com\/index.php?rest_route=%2Fwp%2Fv2%2Ftags&post=6536"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}USE OUR CONTENT<\/h3>\n