Insurers are under fire for giving consumers bad information about which providers are in their plan network. The controversy raises a simple question: Is it really so hard to maintain an accurate provider directory?
The inaccuracies have drawn criticism from California regulators and proposals for stricter oversight from the nation's insurance commissioners and the Obama administration.
Reliable provider directories are more critical than ever now that millions of Americans are expected to choose their own health plans in the new marketplaces, consumer advocates say, especially given that many lower-cost coverage options have very narrow provider networks.
Insurers say inaccurate directories can be blamed on several factors: software glitches; problems with providers communicating updated information; and the enormous task of keeping track of thousands of doctors over several networks.
“It's changing all the time,” Dan Schuyler, Leavitt Partners' senior director of exchange technology said. “[There are] dozens of plans with dozens of different networks, and so you have all this churn that's occurring. It's very difficult to keep these provider directories updated, certainly on a daily basis.”
The California Department of Managed Health Care last month slammed two of the state's biggest insurers, Blue Shield of California and Anthem Blue Cross and Blue Shield, for failing to give consumers accurate network information for plans sold in the state's marketplace, Covered California.
The agency said wrong locations or plan statuses were listed for many of the physicians listed in the plans' directories. The state also called thousands of physicians' offices and found that many of the providers listed were not in the plan's network.
The two Blues companies responded that the lists are constantly changing and very large—38,000 physicians in the case of Anthem. Blue Shield emphasized that physicians need to more proactively update the insurer about their status changes.
Clare Krusing, a spokeswoman for America's Health Insurance Plans, said that accurate directories are a “shared responsibility” and providers often “just aren't providing information in a timely manner.”
Insurers also say their efforts are frustrated by software limitations.
Josh Nelson, vice president of provider network development with Utah co-op Arches Health Plan, said the company's software differentiates doctors by tax ID number. But doctors often use the same number across different practices, and Arches sometimes wants doctors to be in-network at some locations but not others.
“There are a lot of cardiologists in the Salt Lake Valley,” Nelson said. “We don't want them all. But if we choose those few that operate in Park City, the system enters all the locations they practice in. … it defeats the purpose of a narrow network.”
But consumer advocates and some industry experts say managing provider directories is a fundamental part of the business that health plans must successfully tackle, regardless of the challenges.
“These explanations are outrageous,” said Robert Laszewski, president of consultancy Health Policy and Strategy Associates. “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, said regulation is needed for insurers to up their game. “It's not competition that will fix the problem. It's invisible to consumers at the point of shopping,” she said.
More regulation may be coming. The National Association of Insurance Commissioners recently revised a model law for states regarding provider networks. It requires that health plans maintain provider directories online and in print and update them at least monthly.
HHS also recently proposed requiring insurers that sell plans on the exchanges to update their directories at least monthly, with detailed information about providers, including whether they are accepting new patients.
But accurate information may not be sufficient. Carriers sometimes put “provider list” links on an insurance exchange website that lead the user to the main page of an insurer's website, without a clear way to get to the provider directory. That problem is less common this year, said Claire McAndrew, private insurance program director with consumer advocacy group Families USA.
Still, insurers' provider directories are often presented in PDF documents that are difficult to understand.
Quincy, of Consumers Union, said plans need to do a better job conveying the “choice architecture” for consumers. Health-coverage shoppers need to know when they're purchasing a plan that restricts provider choice to a narrow network, and they need to be able to compare plan networks in the marketplace.
Schuyler said centralized network comparison tools are tricky for exchanges to execute. Insurers often have different conventions for listing providers, which requires exchanges to translate the lists into a common standard. And because it's hard to update directories in real time, the freshest data will often be on the insurers' websites.
HHS, in a proposed rule issued in November, indicated that officials are considering requiring plans to post directories to their websites in a “machine-readable file” that would enable third parties to create tools to help consumers make more informed decisions.
The payoff for consumers is substantial, said Dr. Joshua Sharfstein, Maryland's secretary of health. The state has launched a centralized provider search tool separate from its exchange, which allows patients to search for doctors and compare plans.
The centralized approach allows providers to find and rapidly correct any errors with all plans on one online location.
The website was fairly inexpensive, Sharfstein said, costing the state a “few hundred thousand dollars.” But he said he isn't sure whether it's a scalable solution nationwide: Maryland has a strong health-information exchange, and the provider search tool relies on that infrastructure as the foundation. States that don't have an HIE will find it a “bigger lift,” Sharfstein said.
Follow Darius Tahir on Twitter: @dariustahir