Provider Directory Management
Addressing the Compliance Challenge for Health Plans and Their Provider Network
Guidelines for maintaining accuracy of provider directories for Medicaid managed care plans, Medicare Advantage plans and Marketplace plans are inconsistent between federal organizations and still evolving at the state level, leaving Accountable Care Organizations in an uncomfortable position and at risk for fines due to compliance violations. All parties agree that having readily available, accurate, up-to-date information is critical to providing health services to members, but the standard for maintaining that information and the best practice methodology for getting there are continually up for dispute.
HealthDetail’s long-established ProviderOne verification services can help maintain the accuracy of your provider directories, limit your exposure to complaint-generated audits and negate the risk of compulsory fines and expensive corrective active plans.
ProviderOne helps maintain your compliance with current CMS guidelines for monthly updates of printed directories and electronic directory updates within 30 calendar days (per 42 C.F.R. § 438.10) employing a broad range of services including: address validation, phone verification, data validation and NPI (National Provider Identifier) Updates.
Ensuring a High-Quality Experience
High Turnover and dated technology leads to deficiencies in your service representatives’ ability to accurately respond to member inquiries. Through our MemberOne services, ongoing evaluation of your staff is completed through inbound inquiries, simulating real life scenarios and a closed loop reporting system. This allows for near immediate delivery of lessons learned back to the individual representative and their supervisors, as well as a roll up of the evaluation and the associated call recordings back into your database for use with all agent training.
Keep Your Readily Accessible Electronic Information Safe and Secure
Support for our services is provided by one of the industry’s most advanced and stable information processing and storage systems. Our—and therefore your—data is stored on a world-class, secure and powerful cloud computing platform that has been operating with a 99.9+ percent uptime record for more than a decade. Cloud computing has become the technology of choice for the majority of large organizations for its convenience, configurability, and redundant safeguards. It is quickly becoming the preferred solution for hosting software and other solutions such as the ones we offer your firm.
Even among cloud offerings, our platform is exceptional. With dozens of servers backing each other up 24/7/365—and capable of processing thousands of database transactions per second—the efficiency and trustworthiness of our processing and storage capabilities are unmatched. At the same time, highly certified engineers monitor our systems around the clock and the most advanced security software available continually scans for—and works to prevent—any hint of an attack.
“Informatica Cloud Services are like sliced bread: quick and easy to use, cost-effective, and popular.”
—Darrell DeVeaux, President and CEO, HealthDetail
HealthDetail specializes in maintaining membership and enrollment data for public health providers and insurers. HealthDetail’s work is split into 3 core areas: member outreach, knowledge and enrollment services. HealthDetail successfully works with many managed care organizations in one of the largest and most complex markets and use innovative technology solutions to resolve simple and complex problems for customers.
By Chad Terhune | February 13, 2017
California’s biggest health insurers reported inaccurate information to the state on which doctors are in their networks, offering conflicting lists that differed by several thousand physicians, according to a new state report.
Shelley Rouillard, director of the California Department of Managed Health Care, said 36 of 40 health insurers she reviewed — including industry giants like Aetna and UnitedHealthcare — could face fines for failing to submit accurate data or comply with state rules.
Rouillard said she told health plan executives in a meeting last week that such widespread errors made it impossible for regulators to tell whether patients have timely access to care in accordance with state law.
“I told the CEOs it looks to me like nobody cared. We will be holding their feet to the fire on this,” Rouillard said in an interview with California Healthline. “I am frustrated with the health plans because the data we got was unacceptable. It was a mess.”
The state wasn’t assessing the accuracy of online provider directories that are used by consumers. But the new report suggests that insurers may be misrepresenting which providers they have under contract or are unable to collect accurate information.
Flawed provider directories are a longstanding problem industrywide, and the proliferation of narrow networks on the Obamacare insurance exchanges and in employer health plans has sparked numerous consumer complaints.
Outdated and inaccurate provider lists can hinder patients from getting treated and, in some cases, lead to huge unforeseen medical bills when people unwittingly go out of network for care.
California officials discovered the latest problems while reviewing annual reports filed by insurers. In those reports, insurers submitted two sets of provider lists, one used during the year to measure patient access and the other a year-end tally. Often they were dramatically different.
UnitedHealthcare, the nation’s largest health insurer, listed 9,135 primary-care doctors on the provider list used during the year who were absent from year-end list — a discrepancy of 45 percent.
Cigna, another big insurer, named 8,572 on the one list who were not on the other, a 36 percent discrepancy. For Anthem Blue Cross, the discrepancy was 8,165 primary-care physicians, or 36 percent, and for Blue Shield of California it was 4,371 primary-care doctors, or 22 percent.
In another instance, the state said Aetna counted the same cardiologists in one county more than 160 times, inflating the number of specialists overall by 2,293. That overstated the list of specialists by 82 percent.
Overall, for seven insurers, the two sets of lists differed by 50 percent or more for in-network specialists.
Rouillard said provider directories can fluctuate over time, so some small variations between one list used during the year and another at year’s end would be expected. But she said the wildly different figures that were reported raised red flags and made it impossible to know whether enough doctors were available to see patients.
Some of these issues are not new. In 2015, California’s managed care agency fined Anthem $250,000 and Blue Shield of California $350,000 for overstating the breadth of their doctor networks.
Both Anthem and Blue Shield of California declined to comment on the state’s most recent findings. Aetna said it was still reviewing the state’s analysis.
Other health insurers referred questions to an industry trade group. Charles Bacchi, chief executive of the California Association of Health Plans, said some mistakes may have been made but emphasized that measuring patient access to physicians is difficult.
“Health plans are committed to providing timely access to health care and we believe that we provide that successfully,” Bacchi said. “Clearly this report demonstrates that we have work to do to improve our survey responses, and health plans are committed to working with the department to address it.”
Under California law, patients must get urgent care appointments within 48 to 96 hours. Primary-care visits must be scheduled within 10 business days and appointments with a specialist must come within 15 business days.
Yet many consumers continue to struggle to find in-network doctors to meet their needs.
David Discher of Redwood City, Calif., said he tried most of last year to find doctors who would take his Anthem Blue Cross insurance. The 39-year-old suffers from psoriatic arthritis and requires regular infusion treatments.
The Anthem directory for consumers listed three rheumatologists in his area. One doctor’s phone was disconnected and the other two were no longer accepting his Anthem plan, Discher said. His joint pain and swelling worsened while he waited nearly two months to see a specialist.
“It boggles my mind that insurers can’t keep their list up to date,” Discher said. “There is no excuse for how messy it is. Health insurers are engaged in false advertising.”
Consumer outrage over provider directories led to passage of a state law last year that requires insurers and medical providers to ensure the lists are accurate and regularly updated. It also requires health plans to reimburse consumers who are charged out-of-network prices because of an inaccurate provider list.
This latest review by regulators stemmed from a 2014 law sponsored by state Sen. Ed Hernandez (D-West Covina) that required insurers file reports to the state to combat problems with provider lists and barriers to care. He and consumer advocates urged regulators to step up enforcement against insurers that are violating the law.
“Their inability to accurately document which providers are in their networks raises serious questions about the reliability of these networks,” said Hernandez, chairman of the Senate Health Committee.
The state report analyzed data for 2015, and it applied to people in employer plans, individual policies and Medicaid.
Only four health plans submitted information without substantial errors. Two were full-service health plans, Community Health Group and Inland Empire Health Plan. The two others specialize in behavioral health: Human Affairs International of California and Managed Health Network.
The next round of reports from insurers on patient access and provider lists are due next month.
Federal officials this month warned 21 Medicare Advantage insurers with high rates of errors in their online network directories that they could face heavy fines or have to stop enrolling people if the problems are not fixed by Feb. 6.
Among the plans that were cited are Blue Cross Blue Shield of Michigan, Highmark of Pennsylvania, SCAN Health Plan of California as well as some regional plans owned by national carriers such as UnitedHealthcare and Humana.
The action follows the government’s first in-depth review of the accuracy of Medicare Advantage provider directories, which consumers and advocates have complained about for years. More than 17 million Americans, or nearly a third of Medicare beneficiaries, get coverage through private Medicare Advantage plans, which are an alternative to traditional Medicare.
The Centers for Medicare & Medicaid Services in October reported some of the results of the audit, but they had not released names or statistics from the individual plans.
“Because Medicare Advantage members rely on provider directories to locate an in-network provider, these inaccuracies pose a significant access-to-care barrier,” Medicare officials wrote in a report released last week outlining the problems.
Unlike traditional Medicare, the private Medicare plans typically restrict beneficiaries to a network of doctors and hospitals.
Piedmont Community Health Plan, a small Medicare plan with about 5,200 members in southwest Virginia, had the highest rate of inaccuracies among the 54 insurers examined. Officials found errors in the listings of 87 of 108 doctors checked in Piedmont’s directory, according to the report. Most of the errors involved providing the wrong locations for doctors and doctors who should not have been listed.
Piedmont officials did not return calls for comment.
Piedmont and two other plans with the highest error rates — a WellCare plan in Illinois and Emblem Health’s ConnectiCare subsidiary — were required by Medicare to submit specific business plans detailing how they intend to address the issue.
The individual plans receiving warning letters cover more than 1.4 million beneficiaries. Most operate in numerous states, although CMS generally limited its review to a specific state or geographic area.
The federal review focused on reviewing primary care doctors, cardiologists, ophthalmologists and oncologists. It involved individual calls to check on the listings for 108 doctors in each health plan. “We encountered several instances where a call to a provider’s office resulted in determining that the provider had been retired or deceased for a long period of time, sometimes years,” the report said.
The CMS report found almost half of the 5,832 doctors listed had incorrect information, including wrong addresses and wrong phone numbers. Most health plans had inaccurate information for between 30 to 60 percent of their providers’ offices, the report said. The report blamed the insurers for failing to do enough to keep their directories accurate. Members rely on the directories in both deciding whether to join a plan and then in searching for doctors to treat them.
“We saw a general lack of internal audit and testing of directory accuracy among many” Medicare Advantage organizations, the report said.
CMS’ survey found the most error-prone listings involved doctors with multiple offices that did not serve health plan members at each location.
The health plans were sent the warning letters Jan. 6 and given 30 days to fix the mistakes or face possible fines or sanctions, which could include suspending marketing and enrollment. CMS officials said the report was not issued before the annual open enrollment period — which ended Dec. 7 — because of the need to allow the health plans to review the findings before the report was made public.
Medicare Advantage members have until Feb. 14 to disenroll and join traditional Medicare but after that they are locked into their plan for the rest of the year. Seniors may be able to request permission to change plans on a case-by-case basis by calling 800-MEDICARE.
Another 32 companies with less serious mistakes also received letters saying their directories did not comply with a rule that took effect last year requiring plans to contact doctors and other providers every three months and to update their online directories in “real time.”
ConnectiCare spokeswoman Kimberly Kann acknowledged the difficulties. “Keeping these directories up-to-date is a two-way street and we are working with doctors and other medical professionals to continue providing quality service,” she said.
WellCare spokeswoman Crystal Warwell Walker said the Tampa, Fla.-based company took the survey results seriously. “We modified our data gathering techniques and online reporting options to ensure that when more than one address is listed for a provider, that provider is practicing at that location on a routine basis and access to care is not compromised,” she said.
CMS is continuing its investigation of provider directories this year and expects to examine all 300 companies by end of 2018.
Kaiser Health News, a nonprofit health newsroom whose stories appear in news outlets nationwide, is an editorially independent part of the Kaiser Family Foundation.
By Jay Hancock | December 5, 2016
Penny Gentieu did not intend to phone 308 physicians in six different insurance plans when she started shopping for 2017 health coverage.
But a few calls suggested to Gentieu, a photographer who lives in Toledo, Ohio, that doctors listed as “taking new patients” in the health plans’ directories were not necessarily doing so.
Surprised that information about something so central to health insurance could be so poor, she contacted almost every primary care physician listed as accepting new patients in every local plan. More than three-quarters of those doctors in her part of Ohio were in fact rejecting new patients, she found.
“It’s just not fair to be baited and switched,” said Gentieu, who must find a new doctor because her physician of several years will not be in any available plans in her area next year. “It’s just so crazy that you’re presented with this big list of doctors and then you call them and you realize there’s nobody there.”
As consumers review their coverage and shop for 2017 insurance through the federal health law’s online marketplaces during the annual open enrollment period, many of the directories they are using are outdated and inaccurate. Some doctors in the directories are not accepting new patients and some are not participating in the network, say experts, brokers and consumers. Still other physicians in the directories, who are listed as “in-plan,” charge patients thousands of dollars extra per year in “concierge fees” to join their practices.
“There continue to be inaccuracy problems,” said Justin Giovannelli, a Georgetown University professor, who studies coverage under the health law. Flawed directories are “a real barrier to accessing the care and accessing the insurance consumers have purchased.”
President-elect Donald Trump has pledged to repeal and replace the Affordable Care Act, which created the marketplaces. But insurers’ doctor lists are likely to remain a problem no matter what the law looks like, consumer advocates say.
Knowing which doctors and specialists are available within a plan is critical, as patients who visit a physician outside a plan’s network must pay much if not all of the cost.
The effect from flawed directories is even greater this year, as carriers have stopped offering coverage in many markets, meaning many consumers have only one or two insurers to choose from. The number of doctors and hospitals in plan networks also continues to shrink as insurers steer patients toward lower-cost narrow networks.
Reports of inaccuracies suggest that new federal rules to ensure reliable directories are having little effect. Starting this year, all plans sold through the marketplaces are required to “publish an up-to-date, accurate and complete provider directory” or be subject to penalties or removed from the marketplace portal.
But so far no plans have been fined or kicked off the enrollment sites for having poor doctor directories, said Aaron Albright, a spokesman for the Centers for Medicare and Medicaid Services, which would enforce the rules. A Health and Human Services Department survey of Medicare plans for those 65 and older that was released in October found errors in nearly half of the listings in doctor directories.
Staci Doolin, a co-owner of a radon-testing company in Forsyth, Ill., consulted the Blue Cross Blue Shield of Illinois physician directory in January to make sure her primary care physician was in the network and even called the insurer to double-check.
The directory was wrong. The doctor was not in the plan.
“I thought I was good to go, and then I get this bill and it says my insurance didn’t cover anything and I owe $503,” Doolin said.
It took until September to resolve the matter — but not before the office threatened to summon a bill collector. She never recovered $100 she spent on a dermatologist who was listed in the directory but who also was not part of the plan.
No comprehensive data exists on doctor directory accuracy. The health law and HHS set standards for network adequacy but leave most enforcement up to states. States rarely test the lists for accuracy and often rely on consumers to report problems.
But third-party surveys frequently reveal big discrepancies. One recently published study showed as many as a fourth of the doctors listed in California directories last year for marketplace plans were not accepting new patients. About one doctor in 10 was not working for the listed practice.
Consumer advocates often praise California for vigorous insurance regulation. Last year, the state fined one plan $350,000 and another $250,000 for flawed doctor directories.
“I have to think it’s pretty much the same nationwide,” said Simon Haeder, an assistant professor at West Virginia University, who led the study. “Insurers have a hard time keeping these up-to-date because it costs a lot of money, and providers don’t put a lot of effort on giving insurers updated information.”
Even doctors offices are frequently unclear about whether they participate in certain plans, said insurance brokers, who assist consumers shopping for plans.
Confusion multiplies when physicians are in some networks and not others offered by the same insurer. Doctors might be part of broader plan with many choices but not part of a narrow network with nearly the same name.
“We’d have customers call up [a doctor] and they’d say, ‘We take Blue Cross PPO,’” said John Jaggi, an Illinois broker. “But they didn’t take Blue Choice Preferred PPO.” Neither the patient nor the doctor’s office knew the difference, he said.
Even when primary-care doctors are in-network and accepting new patients, they increasingly charge expensive “concierge” fees on top of the usual deductibles, co-pays and premiums required by the policy, brokers say.
The primary-care roster for two plans from Florida Blue, the Blue Cross insurer in that state, lists four physicians working for NCH Healthcare, a Naples hospital system. One practiced at Harvard University and another worked for the Cincinnati Bengals football team.
What the directory doesn’t say is that seeing those four doctors costs patients an extra $3,000 a year in addition to thousands of dollars in premiums and deductibles.
Florida Blue cannot discuss contracts with network doctors and is unaware of recent complaints about concierge fees, said company spokesman Paul Kluding.
Directories for specialty physicians may be even more difficult to navigate than those for primary care doctors.
Brian Jarvis, who lives near Dayton, Ohio, needed an orthopedist after straining an Achilles’ tendon this summer. He had to go through 17 doctors listed as accepting his marketplace plan before finding one who really did, he said.
An online tool for Florida Blue does not let consumers search for anesthesiologists, who are often outside coverage networks even when their hospital is in network. Unwittingly being put under by a non-network anesthesiologist can cost patients thousands of dollars.
Even insurers admit patients are ultimately on their own to navigate the directory thicket.
“We recommend you contact the provider to confirm that they are in your plan and that the desired service is covered,” warns the online doctor-search tool for Anthem, one of the biggest sellers of marketplace plans under the health law.
Few consumers take that advice to heart like Gentieu.
“I was shocked at how awful the state of Ohio is for handling all of this,” said Gentieu, who was concerned about having a five-year-old hip replacement monitored.
She posted results on her website and sent complaint letters to plans and the Ohio Department of Insurance. Four of the insurers did not substantially dispute Gentieu’s research.
“While our findings do not exactly match those of Gentieu, we did identify issues which are being addressed,” said Don Olson, a spokesman for Medical Mutual of Ohio, a health insurer in the state.
Gentieu found that only 15 percent of those listed as primary care doctors in one Medical Mutual network were actually primary care physicians taking new patients. Many had not accepted new patients in years. Others were specialty doctors, nurse practitioners or medical residents who had not completed their training.
Physicians often fail to tell insurers when they stop accepting patients for certain plans, Medical Mutual and other carriers said.
Like HHS, Ohio instituted new directory-accuracy rules this year for marketplace plans. But enforcing them is “consumer-driven,” said David Hopcraft, a spokesman for the Ohio Insurance Department. The state does not check the lists until consumers report inaccuracies, one doctor at a time.
“That is completely insufficient,” said Lynn Quincy, a health care specialist for Consumers Union. “Only 13 percent of the non-elderly adult population know they have a state insurance department, so clearly that’s a pretty bad setup.”
Kaiser Health News, a nonprofit health newsroom whose stories appear in news outlets nationwide, is an editorially independent part of the Kaiser Family Foundation.
By Phil Galewitz | October 24, 2016
Provider directories for private Medicare Advantage plans are riddled with errors, according to the government’s first in-depth review.
The results made public Monday, arriving amid the annual enrollment period through Dec. 7, validate gripes long made by seniors and consumer advocates. The level of errors still surprised regulators, said officials from the Centers for Medicare & Medicaid Services who disclosed their findings at an industry conference in Washington.
Incorrect information was found for almost half of the 5,832 doctors listed in directories for 54 Medicare Advantage plans checked last fall, they said. Only online directories were examined.
The government hopes that a new rule this year will help raise that bar because it requires Medicare Advantage plans to contact doctors and other providers every three months and update their online directories in “real time.”
CMS did not identify the names of insurers that were surveyed.
CMS’ survey found the most error-prone listings involved doctors with multiple offices that did not serve health plan members at each location, said Christine Reinhard, a health insurance specialist in the CMS Division of Surveillance, Compliance and Marketing.
Explanations could be that the doctor was retired, worked at a different location or never worked at the address. Or maybe the doctor never had a contract with the Medicare health plan — a less likely possibility, according to officials.
The review also uncovered:
- Wrong phone numbers for 521 doctors’ offices.
- Wrong addresses for 633 doctors’ offices.
- Error rates that exceeded 60 percent of the doctors surveyed for five Medicare Advantage plans.
CMS has not issued any fines but that could still occur, said Jeremy Willard, also a health insurance specialist in the CMS surveillance division. Inaccuracies found in the Medicare Advantage directories could lead to penalties up to $25,000 a day per beneficiary or bans on new enrollment and marketing.
Senior citizens rely on provider directories when choosing a health plan to identify in-network doctors. They also use them when seeking referrals to specialists.
“Errors jeopardize the beneficiary’s ability to be connected with a needed provider,” Willard said.
CMS carried out the survey by randomly calling 108 doctors representing primary care, cardiology, ophthalmology and oncology for the Medicare Advantage companies. The highest error rates involved primary care physicians and cardiologists.
America’s Health Insurance Plans, the industry trade group, said its companies work hard to make provider directories accurate and keep them up-to-date.
“That’s what consumers need — and that’s what we’re committed to improving,” said spokesman David Merritt, acknowledging that plans needed to do better.
More than 17 million Americans, or nearly a third of Medicare beneficiaries, get coverage through Medicare Advantage plans.
Medicare Advantage plans and most exchange plans restrict coverage to a network of doctors, hospitals and other health care providers that can change during the year.
CMS is also surveying Medicare Advantage companies this fall, and officials hope to survey every company by 2018 when the three-year review will be completed.
Kaiser Health News, a nonprofit health newsroom whose stories appear in news outlets nationwide, is an editorially independent part of the Kaiser Family Foundation.
By Emily Bazar | September 6, 2016
SACRAMENTO, Calif. — State Sen. Ed Hernandez and his wife, Diane, are optometrists.
Diane handles some insurance matters for their practice, and she recently told him that a health plan had emailed to request more information: It wanted confirmation that they were both participating providers, he says.
“I didn’t say anything because I was afraid she’d be mad at me,” says Hernandez, D-West Covina.
That’s because the additional paperwork was probably his doing.
Hernandez, who chairs the California Senate Health Committee, is author of a newly enacted state law that aims to improve provider directories, long riddled with out-of-date and inaccurate information.
Under the law, insurance companies — and health care providers like the Hernandezes — must comply with new requirements to keep directories updated at least every quarter.
The law, which took effect July 1, also provides patients with some firepower to fight surprise medical bills that result from directory errors.
The law’s reach is broad: It applies to Covered California and private market plans, as well as Medi-Cal managed care and most job-based insurance policies.
The inaccuracy of directories, Hernandez says, “has been and … seems to continue to be a problem that needs to be rectified.”
Several other states, from Georgia to Maryland, have passed similar legislation or are considering doing so, says Claire McAndrew, private insurance program director for Families USA, a national health care consumer advocacy group. In some states, insurance commissioners have adopted new rules through the regulatory process.
But California’s law “is the most comprehensive,” she says. “The level of detail in California goes beyond any other state.” Federal officials also instituted a rule this year requiring directories be updated monthly for all plans sold on the 37 state marketplaces run by the federal government.
And they set new rules for Medicare Advantage plans, requiring that the companies contact doctors every three months and update their online directories within 30 days. A recent study in the journal Health Affairs found that provider directories for some health plans sold through Covered California and in the private market are so inaccurate that they create a “disheartening” situation for consumers trying to find doctors.
That finding was confirmed this month when the state Department of Managed Health Care (DMHC) announced that Anthem Blue Cross and Blue Shield of California — which were previously fined for inaccuracies in their Covered California provider directories — still had “disappointing” directory problems.
“We are optimistic and hopeful that the law … will help,” says department director Shelley Rouillard.
Among the law’s new rules:
- Health plans must update their printed directories at least every quarter and their online directories at least every week if providers report changes.
- Provider directories must be posted online and be available to anyone, not just enrollees. Print directories must be available upon request.
- The directories must “prominently” display directions for consumers who want to report inaccuracies. Upon receiving complaints, plans have 30 business days to makes changes, if necessary.
- Providers must inform plans within five business days if they are no longer accepting new patients — or, alternately, if they will start accepting them.
- Health plans can delay payments to providers who fail to respond to attempts to verify information.
The California law also gives consumers recourse. Let’s say you use a provider directory to find a doctor but you’re billed the out-of-network price because the directory was wrong. In that case, health plans must reimburse you the amount beyond what you would have paid to see an in-network doctor.
If you find yourself in this situation, first take your complaint to your plan, advises DMHC’s Rouillard. You will have at least 180 days from the date you received the bill to file a grievance.
“You’ll probably have to make a case” to the plan, Rouillard says. “You should explain what you did, when you looked at the directory, and that you relied on that information.”
Documentation could help your case.
That’s something to consider when you’re searching for a provider in the first place. It wouldn’t hurt to save a screen shot from the online directory showing the doctor is in-network, or take detailed notes if you call your plan’s customer service line.
“Keep copies of everything, and note the date, time and name of anyone you speak to,” says Nancy Kincaid, spokeswoman for the state Department of Insurance.
Plans have 30 days to investigate and respond to your complaint. If the situation isn’t resolved to your satisfaction, your next step is to take your grievance to your health plan’s regulator.
Since the law went into effect, the DMHC has helped one consumer get reimbursed as a result of this law.
But, “I’m hoping consumers don’t have to go through process. I’m hoping the directories are accurate,” Hernandez says.
It might take time to get there, as health plans implement the new requirements — as well as others that will take effect in the coming months — and work with providers to update the information.
“This is so early and there are so many errors,” Rouillard says.
By Susan Jaffe | March 9, 2015
Starting next year, the federal government will require health insurers to give millions of Americans enrolled in Medicare Advantage plans or in policies sold in the federally run health exchange up-to-date details about which doctors are in their plans and taking new patients.
Medicare Advantage plans and most exchange plans restrict coverage to a network of doctors, hospitals and other health care providers that can change during the year. Networks can also vary among plans offered by the same insurer. So it’s not always easy to figure out who’s in and who’s out, and many consumers have complained that their health coverage doesn’t amount to much if they can’t find doctors who accept their insurance.
Under a rule published last month by the Centers for Medicare & Medicaid Services, Medicare Advantage plans must contact doctors and other providers every three months and update their online directories in “real time.” Online directories for policies sold through healthcare.gov, the health law exchange run by the federal government in 37 states, must be updated monthly, CMS announced in a separate rule.
Inaccuracies in the Medicare Advantage directories may trigger penalties of up to $25,000 a day per beneficiary or bans on new enrollment and marketing. CMS will also use the directories to help determine whether insurers have enough doctors to meet beneficiaries’ needs.
The federal exchange plans could face penalties of up to $100 per day per affected beneficiary for problems in their directories.
“Studies have shown massive error rates in these directories, including states in the federal exchanges,” said Lynn Quincy, associate director for health policy at Consumers Union. “If consumers select a health plan because they believe their hospital or physician is a participating provider and it later turns out that’s an error, right now they rarely have a remedy–they are stuck with that plan for the year.”
“Regulators also rely on these provider directories to make assessments about network adequacy,” said Quincy. “And when provider directories include physicians who have died, moved out of state, or aren’t accepting new patients, we are overstating how adequate the network is.”
The administration last year announced rules designed to make sure those networks have adequate numbers of providers. The newest rules will help guarantee that consumers get good information on those networks.
Nearly 9 million people have enrolled in plans on the federal marketplace for 2015, according to officials.
Some states running their own health exchanges, including New York and California, also require frequent directory updates.
Californians have had trouble finding doctors in their plans and others who were misled into thinking their providers were in network have been “socked with huge out-of-network bills,” said California Insurance Commissioner Dave Jones, who issued an emergency regulation requiring plans to update their directories weekly.
The new Medicare Advantage rules are a response to complaints from beneficiaries and doctors about “directories including providers who are no longer contracting with the [plan], have retired from practice, have moved locations, or are deceased,” CMS officials said in the notice to insurers. Some directories also list providers who are still in the plan’s network but not available to new patients.
About 16 million seniors have signed up for the private Medicare Advantage plans, which are an alternative to traditional Medicare.
“We have had clients either start treatment with a doctor who doesn’t stay in the network for the whole year or think they are they are picking a plan that covered a certain doctor and then found out it did not,” said Jen Tayabji, coordinator of the Champagne County Health Care Consumers’ Medicare task force in central Illinois. Because most Medicare Advantage members are locked into their plans for the calendar year, she said they often don’t have good alternatives when their provider networks shrink.
“It is critically important that people with Medicare have timely access to the information they need to make decisions about their care,” said Medicare spokesman Raymond Thorn. “Reflecting this priority, Medicare will be requiring health plans to ensure that their online directories are up-to-date and accurate as soon as their networks change.”
Medicare Advantage plans had mixed reactions to the new rules. Some are concerned about increased cost of compliance. Matt Burns, a spokesman for UnitedHealthcare, one of the largest Medicare Advantage providers, said the company was still reviewing the rules. Other companies referred questions to an industry trade association, America’s Health Insurance Plans.
“It’s important to keep in mind that maintenance and accuracy of online directories is a two-way street, and it is often difficult getting providers to report changes in their status in a timely manner,” said the association’s spokeswoman Clare Krusing.
“This is definitely the direction that we need to go to make sure the Medicare Advantage plans don’t gut their networks,” said Mark Thompson, executive director of the Fairfield County Medical Association, which sued UnitedHealthcare in 2013 to stop the terminations of Connecticut doctors from its Medicare Advantage plans.
Cigna’s Medicare Advantage directories are updated weekly during the open enrollment period and monthly the rest of the year, said spokesman Joe Mondy. Aetna’s Medicare Advantage directories are updated nightly, six days a week, and weekly for directories from subsidiary Coventry, said spokesman Kendall Marcocci.
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