If you have medical insurance, chances are you've been utterly exasperated at some point while trying to find an available doctor or mental health practitioner in your health plan's network.
It goes like this: You find multiple providers in your plan's directory, and you call them. All of them. Alas, the number is wrong; or the doctor has moved, or retired, or isn't accepting new patients; or the next available appointment is three months away. Or perhaps the provider simply is not in your network.
Despite a spate of state and federal regulations that require more accurate health plan directories, they can still contain numerous errors and are often maddeningly outdated.
Flawed directories not only impede our ability to get care but also signal that health insurers aren't meeting requirements to provide timely care — even if they tell regulators they are.
Worse, patients who rely on erroneous directory information can end up facing inflated bills from doctors or hospitals that turn out to be outside their network.
In 2016, California implemented a law to regulate the accuracy of provider directories. The state was trying to address long-standing problems, illustrated by an embarrassing debacle in 2014, when Covered California, the insurance marketplace that the state formed after the passage of the Affordable Care Act, was forced to pull its error-riddled directory within its first year.
Also in 2016, the federal Centers for Medicare & Medicaid Services demanded more accurate directories for Medicare Advantage health plans and policies sold through the federal ACA marketplace. And the federal No Surprises Act, which took effect this year, extends similar rules to employer-based and individual health plans.
California law and the federal No Surprises Act stipulate that patients who rely on information in their provider directories and end up unwittingly seeing doctors outside their networks cannot be required to pay more than they would have paid for an in-network provider.
Unfortunately, inaccurate directories continue to plague our health care system.
A study published in June in the Journal of Health Politics, Policy and Law analyzed data from the California Department of Managed Health Care on directory accuracy and timely access to care. It found that in the best case, consumers could get timely appointments in urgent cases with just 54% of the doctors listed in a directory. In the worst case: 28%. For general care appointments, the best case was 64% and the worst case 35%.
A key takeaway, the authors write, is that "even progressive and pro-consumer legislation and regulations have effectively failed to offer substantial protection for consumers."
Few people know this better than Dan O'Neill. The San Francisco health care executive called local primary care doctors listed in the directory of his health plan, through a major national carrier, and could not get an appointment. Nobody he talked to could tell him whether UCSF Health, one of the city's premier health systems, was in his network.
"I spent close to a week trying to solve this problem and eventually had to give up and pay the $75 copay to go to urgent care because it was the only option," O'Neill says. "I now live a seven- or eight-minute walk from the main UCSF buildings, and to this day, I have no idea whether they are in my network or not, which is crazy because I do this professionally."
Consumer health advocates say insurers are not taking directory accuracy seriously. "We have health plans with millions of enrollees and hundreds of millions in reserves," says Beth Capell, a lobbyist for Sacramento-based Health Access California. "These people have the resources to do this if they thought it was a priority."
Industry analysts and academic researchers say it's more complicated than that.
Health plans contract with hundreds of thousands of providers and must constantly hound them to send updates. Are they still with the same practice? At the same address? Accepting new patients?
For doctors and other practitioners, responding to such surveys — sometimes from dozens of health plans — is hardly at the top of their to-do list. Insurers typically offer multiple health plans, each with a different constellation of providers, who don't always know which ones they're in.
The law gives insurers some leverage to induce providers to respond, and a whole industry has sprung up around collecting provider updates through a centralized portal and selling the information to health plans. The inaccuracy problem remains, however. Health plans and providers often have outdated data systems that don't communicate with each other.
A significant improvement in health plan directories will require "more connectivity and interoperability," says Simon Haeder, an associate professor at Texas A&M University's School of Public Health and a co-author of the study on directory accuracy and timely access.
Until that day comes, you will need to fend for yourself. Be diligent when using your health plan's provider directory. You should use it as your first stop — or to check whether a doctor recommended by a friend is in your network.
Remember the laws that say you can't be charged out-of-network rates if the doctor you visit was listed in your health plan's directory? You'll have to prove that was the case. So take a screenshot of the directory showing the provider's name and save it. Then, call the doctor's office to double-check. Take notes and get the name of the person you talked to. If there's a discrepancy, call your health plan, too.
If you find an inaccurate entry, report it to your health plan. California law requires plans to provide instructions for consumers to do that. If you are in a commercial health plan, your policy is likely regulated by the Department of Managed Health Care. You can lodge a complaint through the department (888-466-2219 or www.healthhelp.ca.gov). Since California's law on provider directories took effect, the department has helped resolve 279 complaints, said spokesperson Rachel Arrezola.
If your plan has a different regulator, the department can point you in the right direction.
If you are one of the roughly 6 million Californians in a federally regulated employer or union plan and you get a big out-of-network bill from a doctor who was listed in your health plan directory, you can file an appeal through the office set up for that purpose (800-985-3059 or www.cms.gov/nosurprises).
Ultimately, efforts to improve the accuracy of provider directories are part of a broader push for greater transparency of health care prices and easier access to patient records. All of that will require a more open information superhighway.
This story was produced by KHN, which publishes California Healthline, an editorially independent service of the California Health Care Foundation.
This article was reprinted from khn.org with permission from the Henry J. Kaiser Family Foundation. Kaiser Health News, an editorially independent news service, is a program of the Kaiser Family Foundation, a nonpartisan health care policy research organization unaffiliated with Kaiser Permanente.