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.
MomSense
So wait are you saying that appropriate government regulation can cause private businesses to become more efficient?
Unpossible!
VOR
We dealt with the office problem when my wife went through chemo. Every January the insurance company would refuse to pay, claiming we were out of network. The issue was that there was a mis-match between the clinic’s HQ address, where billing happened, and the clinic address where the actual treatment occurred. They would figure it out after 3-4 weeks. And then it happened again the next year once things reset on January 1st, same clinic, same issue. Clinic had been at the same location for well over 10 years.
pseudonymous in nc
This op-ed in the NYT by doctors complaining about “financial forces” like performance metrics are corrupting the “bond of trust” between physician and patient reminds me of Emerson’s line about counting your spoons.
ecks
Why is the physical address necessary to match claims? If I move house, my credit card does not stop working, my mobile phone doesn’t drop out, so why is it not possible to have corporate identifiers for doctor offices that don’t require a physical address to validate it?
Mike J
Just mail all payment to the address where treatment takes place and let providers forward it to their HQ themselves. You’ll know very quickly when they move.
Richard Mayhew
@ecks: There are a couple of different claims systems. Some are location based systems that won’t pay a claim unless the combination of Provider ID/Provider NPI, Tax ID, Location ID all match to par locations, and others just use the Tax ID as the determinant of PAR status to pay claims. The location based systems provider much finer control and evaluation data than the Tax ID claims payments.
So it really depends on the claims payment model the insurer uses. Some companies would not care if you get care from a par TIN in California or Colorado while other claims payment systems care if your care was in the strip mall or the office building in the strip mall parking lot.
VFX Lurker
This is part of the reason I prefer Kaiser Permanente coverage over fee-for-service coverage like Aetna. If I walk into a Kaiser clinic or Kaiser hospital, I’m pretty sure my Kaiser coverage will work.
Mnemosyne
There’s also the fact that Anthem BC/BS of California are known bad actors who actively try to screw over their customers. They have been fined multiple times by state regulators even before Obamacare came in, and they just keep on being assholes.
So, yeah, this is no error. This is business as usual for them.
Xantar
News for Marylanders: the new Maryland Health Connection website works. I’ve been beta-testing it for months as part of my job, and it fully opened for business today. I had an account created and started shopping within 15 minutes (I didn’t enroll because I’m going to get insurance through work next year),
Yes, the whole rollout was an epic clusterfuck last year. But this year it’s working the way it should and aside from a few relatively rare cases such as people with ambiguous immigration status, it will give you the correct determination and calculation.
It really works. Go check it out and tell your friends.
Richard Mayhew
@Xantar: That seems to be the big story this year — no colossal fuck-ups which is great news.
NonyNony
@MomSense:
Less efficient, not more. Because money that would be going into profit for shareholders and/or compensation for highly paid upper level employees is instead being spent on providing service to customers. Which is a net loss for the business, though a benefit for the customers.
Efficiency in business is about getting the most amount of money for the least amount of expenditure. The more you have to spend to get an outcome, the less efficient you are. The grand lie that corporations tell us is that improvements in efficiency are a net good for customers – this is not always the case. This is a classic case of an increase in business efficiency at the expense of customer service. And something that the market won’t correct (because nobody is able to jump from provider to provider based on the quality of their network directories – especially if they are all sucky and inaccurate). A place where regulation is needed to force the company to do the right thing for the customers because the market won’t do it for us.
Kent
Richard
I don’t always have comments on your posts but I just gotta say that I totally appreciate the inside picture you are providing into an industry that I (and most of us) really has no real knowledge about. Your posts are always informative and eye opening. And being married to a family physician I should know more about this stuff. Keep them coming!