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In California, a survey found significant inaccuracies in provider directories posted online—may trigger action by regulators to have insurers address this problem

Transparency in healthcare is an important trend. In recent years, much attention has been given to increasing the transparency of the prices charged to patients by hospitals, physicians, and medical laboratories. But now the transparency trend is about to drive change in the provider directories that health insurance plans make available to their beneficiaries and consumers.

When choosing a health plan, many people look for insurance that includes their own physician, or at least a doctor close to home. That is why an accurate and up-to-date provider list is essential to consumer choice and access.

But many health insurers fall short in this regard. California recently released chastising reports on two of its major health plans, Anthem Blue Cross and Blue Shield (ABCBS) (NYSE:WLP) and Blue Shield of California, (BSCA) for publishing inaccurate provider lists on the state’s California Covered insurance exchange.

Survey Finds Major Errors in Provider Directories of ‘Blue’ Health Plans

The California Department of Managed Health Care (CDMHC) found that 12.5% of physicians listed in the Anthem exchange plan’s provider directory had inaccurate locations. A survey of physicians listed as “in network,” revealed that thousands of them, nearly 13%, did not accept Covered California patients.

Likewise, the state reported that 18.2% of locations for physicians listed as providers for Blue Shield’s California Covered plan were inaccurate. Moreover, 9% of doctors listed as “in network” did not accept patients covered by this health plan.

“You can’t have health reform that’s based on insurance markets that are selling standard products and not have this information available to consumers and purchased,” stated Gerald Kominski, Ph.D., Director of the University of California Los Angeles (UCLA) Center for Health Policy Research in a report published by Modern Healthcare.

“What’s the point of open enrollment if you can’t be an informed decision maker?” added Kominski. “It’s crucial states follow up on this and hold insurers accountable.”

State regulators referred the findings to the California Office of Enforcement. They also warned that the CDMHC would conduct a follow-up survey in six months. While there were no immediate consequences for insurers failing to provide consumers accurate information, the reports focused on stricter oversight of insurers participating in Obamacare insurance exchanges. Such oversight not only included the state of California, but also the National Association of Insurance Commissioners (NAIC) and U.S. Department of Health & Human Services (HHS), noted another Modern Healthcare report.

Georgetown University Researchers Cite Consumer Complaints Nationwide

California is not the only state where insurers are failing to provide health plan shoppers accurate provider information. A recent study by Georgetown University’s Center on Health Insurance Reforms found that consumers nationwide complain about inaccurate or obsolete provider directories. Few states, however, are doing anything to improve the situation, the authors said.

This problem is significant enough on a nationwide scale that the NAIC has revised its “model law” for states’ health plans to require insurers to update their provider directories monthly. HHS has also proposed a new rule that would require insurers in Obamacare exchanges to let consumers know which providers are accepting new patients.

Additionally, HSS has proposed a rule that would require health plans to post provider directories in a “machine-readable” file format. This would enable third parties, such as states and consumer advocacy organizations, to create tools that help consumers make more informed decisions.

Joseph-Sharfstein MD

Joshua Sharfstein, M.D. (pictured above) Secretary of Health and Mental Hygiene for the State of Maryland from 2011-14, noted that a proposal by Health and Human Services to require health plans to post provider directories in a “machine-readable” file format would allow third parties to create tools to help consumers make an informed choice when buying a health plan. (Photo in the Public Domain.)

Maryland, for example, launched a search tool that allows consumers to search for doctors and compare health plans on its insurance exchange. Centralizing provider information for all plans on the health insurance exchange in one online location allows providers to rapidly find errors in network directories and make corrections, noted Joshua Sharfstein, M.D., the state’s former Secretary of Health and Mental Hygiene.

Health Plans Blame Inaccuracies on Software, Doctors, and Size of Networks

California’s two Blues blamed the inaccuracies on several factors. These included software glitches, providers failing to update their information, and difficulty tracking constant changes by the enormous number of providers in their networks.

Anthem, Inc., the parent company of ABCBS, for example, has 38,000 physicians in its California network. Accurate provider directories are a “shared responsibility” of providers, pointed out Clare Krusing, spokesperson for America’s Health Insurance Plans (AHIP), and they “just aren’t providing information in a timely manner.”

Insurers also say software limitations may exacerbate inaccuracies. Josh Nelson, Vice President of Provider Network Development at the Utah co-op Arches Health Plan, explained that some physicians accept Arches patients at one location, but not another. Since the company’s software identifies physicians by tax IDs across their various practices, a doctor may be “in network” at one location, but not at another.

Industry Experts, Consumer Advocates ‘Call Out’ Health Plans for Errors

Calling insurers’ explanations “outrageous,” healthcare consultant Robert Laszewski, President of Health Policy and Strategy Associates, observed in a Modern Healthcare report, “Not having accurate consumer-level information about just who is in their provider network—particularly when they are using narrow networks as such a major part of their Obamacare offerings—is inexcusable!”

Lynn Quincy, Associate Director of Health Reform Policy at Consumers Union, noted this problem won’t be fixed by competition, since it’s invisible to consumers shopping for health insurance.

Lynn Quincy

Lynn Quincy (pictured above), Associate Director of Health Reform Policy at Consumers Union, says competition won’t cure the problem of inaccuracies in provider directories, because those shopping for health plans are unaware there is a problem. (Photo copyright Consumers Union.)


Why Provider’s Should Check Their Directory Listings

Hospitals, physicians, clinical laboratories, pathology groups, imaging facilities, and other providers need to know if their patients are covered by health insurance, so they all have a stake in the accuracy of information provided to consumers. The fact that state and federal agencies consider inaccurate provider directories a significant problem should be a wake-up call for all healthcare providers to check their own directory listings for errors and correct them.

Related Information:

Why Can’t Insurers Publish Accurate Provider Directories?

Inaccurate Provider Directories Blamed on Weak Tech, Network Churn

Insurers Draw Heat for Error-Riddled Provider Directories

2014’s Healthcare Price Transparency Report Card Reveals Few States Are Making It Easy and Fast for Consumers to See the Prices Charged by Hospitals, Physicians, and Medical Laboratories 

Innovative California NPR Project Takes on Healthcare Pricing Transparency 

Study at Johns Hopkins Shows Price Transparency Works: Physicians Order Fewer Clinical Pathology Laboratory Tests When They Know the Cost 

Public Hospital in Phoenix Slashes Patient Self-Pay Prices by 50% to Increase Hospital Price Transparency