Since the implementation of Affordable Care Act (ACA), volume and variety of health insurance products have increased to accommodate the expanding market. With this concern over the network adequacy and provider directory has also risen. Consumers have complained over misleading and inaccurate information available across Health Plans Provider Directories.
In November, the California Department of Managed Health Care (DMHC) announced it issued fines against Blue Shield of California ($350,000) and Anthem Blue Cross ($250,000) for inaccurate provider directories. According to Los Angeles Times, “At issue were the companies’ error-riddled provider directories that frustrated many consumers statewide as they tried to find doctors during the rollout of the Affordable Care Act in 2014. As a result, some patients incurred big unforeseen medical bills because they unwittingly went out of network for care.”
Another instance that comes to mind is when the Centers for Medicare & Medicaid Services (CMS) fined Aetna $1 million in 2015 for wrongly telling Medicare Part D beneficiaries that nearly 6,900 pharmacies listed in the health insurer’s provider directories were in-network when they were actually out-of-network.
While the fines may seem paltry for a big Health Plan, the repercussions of the inaccurate Provider Directories can be significant and pose a high risk for both consumer and Health Plans. Blue Shield, for example has already had to reimburse more than $38 million to enrollees who incurred out-of-network costs.
Consumers are at risk of being charged higher out-of-network expenses when Providers are inaccurately listed in the directories. Health Plans, on the other hand are at the greater risk of litigation, government penalties, investigations and significant administrative costs associated with the inaccurate directories.
The Lawmakers at Work
Recently, in response to consumer complaints, California lawmakers approved legislation in 2015 requiring insurers to update their provider directories weekly to improve accuracy. The scrutiny on these plans will likely to continue in the coming years and their peers will probably feel the impacts as well.
The issue is not limited to California. In February, the Center for Medicare and Medicaid Services (CMS) issues the “FINAL 2016 Letter to Issuers in the Federally-facilitated Marketplaces” which details measures specific to QHP (Qualified Health Plan) Provider Directories. These guidelines requires QHP to publish an up-to-date, accurate and complete provider directory including the information on which providers are accepting new patients, the provider’s location, contact information, specialty, medical group, and any institutional affiliations, in a manner that is easily accessible to plan enrollees, prospective enrollees, the State.
Moreover, as per the letter, A provider directo¬ry will be considered up-to-date if it is updated at least monthly and easily accessible when the general public is able to view all of the current providers for a plan in the provider directory on the issuer’s public website.
CMS officials have conveyed that they established these provider directory requirements to enhance the transparency of QHP provider directories and to help consumers make more informed decisions about their health care coverage. Most of this is not new information for a Health Plan. Maintaining up to date and accessible Provider Directories is a big challenge for many.
Common sense dictates that the 2017 Letter will likely contain more stringent requirements than in the past years. Thus, a pertinent question doing the rounds is: How is your Health Plan addressing this and how to go about selecting the right tools to remain complaint? Please share your comments/thought below.