Insurers’ faulty directories leave patients scrambling for network doctors

WASHINGTON – Penny Gentieu had no plans to phone 308 doctors from six different insurance plans when she started shopping for 2017 health coverage.

But a few calls suggested to Ms Gentieu, a photographer who lives in Toledo, Ohio, that doctors listed as “taking new patients” in health plan directories don’t necessarily do so.

Surprised that the information on something so central to health insurance could be so poor, she contacted almost all of the primary care physicians listed as accepting new patients in each local plan. More than three-quarters of those doctors in her part of Ohio were actually rejecting new patients, she found.

“It’s just not fair to be baited and traded,” said Gentieu, who must find a new doctor because her multi-year doctor won’t be in any of the plans available in her area next year. “It’s so crazy that you get presented with this big list of doctors, then you call them up and realize there’s no one there.”

As consumers review their coverage and purchase 2017 insurance from Federal Health Act online marketplaces during the annual open enrollment period, many of the directories they use are out of date and inaccurate.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 “off plan,” charge patients thousands of additional dollars per year in “concierge fees” to join their practice.

“There are always issues of inaccuracy,” said Justin Giovannelli, a professor at Georgetown University, who studies coverage under the health law. Defective directories are “a real obstacle to access to care and access to the insurance that consumers have taken out”.

President-elect Donald J. Trump has pledged to repeal and replace the Affordable Care Act, which created the markets. But insurers’ doctor lists are likely to remain a problem regardless of the form of the law, according to consumer advocates.

Knowing which doctors and specialists are available within a plan is critical, as patients who see a physician outside of a plan’s network have to pay a large part, if not all, of the costs.

The effect of faulty directories is even greater this year, as insurers have stopped offering coverage in many markets, meaning many consumers only have one or two insurers to choose from. The number of doctors and hospitals in plan networks also continues to decline as insurers refer patients to narrow networks at lower cost.

Reports of inaccuracies suggest that new federal rules to ensure directory reliability are having little effect. Starting this year, all plans sold on marketplaces must “publish an up-to-date, accurate and complete supplier directory” or be subject to penalties or removed from the marketplace portal.

But so far, no plan has been fined or excluding listing sites for having bad physician directories, said Aaron Albright, spokesperson for the Centers for Medicare and Medicaid Services, who would apply the rules. A Department of Health and Human Services survey of medicare plans for people 65 and over released in October found errors in nearly half of the listings in physician directories.

Staci Doolin, co-owner of a radon testing company in Forsyth, Ill., Checked 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 ready to go, then I get this bill and it says my insurance doesn’t cover anything and I owe $ 503,” Ms. Doolin said.

It took until September to resolve the issue, but not before the office threatened to summon a bill collector. She never got back the $ 100 she spent on a dermatologist who was in the directory but was also not on the plan.

No complete data exists on the accuracy of the physician directory. The Health Act and the Department of Health and Human Services set standards for network adequacy, but leave most enforcement action to the states. States rarely test the accuracy of listings and often rely on consumers to report problems.

But surveys conducted by third parties frequently reveal big discrepancies. A recently published study showed that up to a quarter of doctors listed in California directories last year for market plans were not accepting new patients. About one in 10 physicians did not work for the listed practice.

Consumer advocates often praise California for its stringent insurance regulations. Last year, the state fined a plan $ 350,000 and $ 250,000 for faulty physician inventories.

“I have to think it’s pretty much the same nationally,” said Simon Haeder, an assistant professor at the University of West Virginia, who led the study. “Insurers find it difficult to keep them up to date because it costs a lot of money and providers don’t go to great lengths to provide insurers with up-to-date information. “

Even medical offices often don’t know if they participate in certain plans, say insurance brokers, who help consumers buy plans.

Confusion increases when physicians are in certain networks and not in others offered by the same insurer. Doctors can be part of a larger plan with many choices, but not part of a narrow network with almost the same name.

Directories of specialist physicians can be even more difficult to navigate than those of primary care physicians.

Brian Jarvis, who lives near Dayton, Ohio, needed an orthopedic surgeon after straining an Achilles tendon this summer. He had to go through 17 doctors listed as agreeing to his market plan before he found one that really did, he said.

An online tool for Florida Blue, that state’s Blue Cross insurer, does not allow consumers to search for anesthesiologists, who are often outside of coverage networks even when their hospital is networked. Being subjected without your knowledge by an anesthesiologist outside the network can cost patients thousands of dollars.

Even insurers admit that patients are ultimately alone in navigating the thicket of directories.

“We recommend that you contact the provider to confirm that it is part of your plan and that the desired service is covered,” warns the online doctor finder for Anthem, one of the largest sellers of plans in the world. market under the Health Act.

Few consumers take this advice to heart like Ms. Gentieu.

“I was shocked at how horrible the state of Ohio is to handle all of this,” said Gentieu, who was concerned about monitoring a five-year-old hip replacement.

She posted the results on her website and sent letters of complaint to the plans and the Ohio Department of Insurance. Four of the insurers did not substantially contest Ms. Gentieu’s research.

“While our findings do not exactly match Ms. Gentieu’s, we have identified issues that are being resolved,” said Don Olson, spokesperson for Medical Mutual of Ohio, a state health insurer. .

Ms. Gentieu found that only 15 percent of primary care physicians listed in a mutual health insurance network were actually primary care physicians taking new patients. Many had not accepted new patients for years. Others were medical specialists, nurse practitioners or medical residents who had not completed their training.

Doctors often fail to notify insurers when they stop accepting patients for certain plans, Medical Mutual and other insurers said.

Like the Department of Health and Human Services, Ohio this year instituted new directory accuracy rules for market plans. But their app is “consumer-centric,” said David Hopcraft, spokesperson for the Ohio Department of Insurance. The state does not verify the listings until consumers report inaccuracies, one doctor at a time.

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