Web directories are one of the key points of differentiation between plans on the Exchanges. A single company can offer half a dozen networks that may all come from the same base but have different inclusions and exclusions. Other plan’s networks may be built as special snowflakes where there is minimal and coincidental commonality with the majority of the other networks offered by the same company. Mayhew Insurance currently is selling to the general public eleven networks and three tiered benefit products that are keyed on networks. We sell four seperate networks on the Exchanges. It is confusing to figure out which doctor is in which network when the directories are perfectly working and reasonably accurate. It is near impossible to figure out if the directories are wildly inaccurate. And that is if you are only looking at Mayhew Insurance. It gets next to impossible if you are looking at four or five seperate companies with four or five seperate networks per company.
California regulators are showing the size of the problem:
a California regulator found that two major health insurers violated state law and significantly overstated the availability of doctors on their new health-law policies.
More than 25% of physicians listed by Anthem Blue Cross and Blue Shield of California were not taking Covered California patients or they were no longer at the location listed by the companies, according to state reports released Tuesday…
For Anthem, the state determined that 12.8% of doctors listed as in-network providers in the exchange were not willing to accept Covered California patients. Another 12.5% were no longer at the location listed in Anthem’s directory.
In examining Blue Shield, the state found that 8.8% of doctors listed were not honoring exchange coverage and 18.2% were not at the location listed by the insurer.
There are two sources of error here that require very different clean-ups by the insurers. The first is scrubbing the list of false providers. The second is cleaning up the office location data set.
Theoretically this is easy. Providers who are par in the product are par in the product and should be displayed on the website. What could be difficult about that?
There are two sources of error on this problem. The first is insurance company side. Someone added a doctor that should not have been on the list to the list. That is fixable fairly easily and internal quality control procedures should be able to minimize these subtypes of problems fairly easily. The root cause is far more interesting as it probably relates to contracting procedures. Some providers are contracted at the individual provider level. Other provider groups will contract at the group or tax identification number (TIN) level. What I am betting is that quite a few of these errors are providers who signed a par contract at the individual level but the TIN never signed on or vice versa. If the TIN signed on, the doctor is par even if s/he does not think so. If the individual provider signed but the TIN did not, that is a fuzzy can of worms for Legal to figure out.
The other source of error is the office manager problem. Office managers will set the receptionist response policy for insurance coverage inquiries. They either might not know that an office is now par in product or they know that they are par, but they are trying to maximize the patient payment mix for that office, so they are saying they are non-par for particularly low paying policies. I don’t know how to fix that problem.
The other error is the office address data management problem. Speaking as a former provider/network data geek, it is a rule of thumb that providers are really bad at providing data which has no immediate claims payment impact. Their logic is that they get buried in enough paperwork so it is either responding to a data request or seeing a patient and getting paid to see a patient. A patient wins all the time. Provider address data is seldom updated off of the recredentialing and recontracting cycle which is often a two or three year cycle.
This is an endemic problem. I was refereeing a college game this fall at a field two hours from my house. A major provider group was supposed to have multiple offices at the strip mall where I was supposed to take a right to get to the field. That strip mall was closed and in the process of being knocked down to create an office park. I sent this info to our outreach folks, and they came back with an answer that the office closed a year ago, and the new office building was a mile away. The group never told us, and looking at our competitors directories, our competitors were clueless as well.
That will be the case until regulators start levying million dollar fines on insurers for ineffective and useless directories. Maintaining good directories is a multi-million dollar a year process and it is often seen as an easy budget savings. The threat of a million dollar fine and potentially a loss of some reimbursement from state programs (CHIP, Medicaid etc) would be a sufficient kick in the ass for insurers to spend more money and time on provider data management.