The Wall Street Journal reports on the new CMS regulations and fines concerning bad provider directories:
Starting Friday, they could be costly for insurers. New regulations allow the Centers for Medicare and Medicaid Services to fine insurers up to $25,000 per beneficiary for errors in Medicare Advantage plan directories and up to $100 per beneficiary for errors in plans sold on the federally run insurance exchanges in 37 states.
This is real money that will transform how directories are seen in insurance companies. Now they are usually a cost center that just has to be good enough to minimize the number of bad press articles in the local newspaper. The Legal department could resolve any big problems that come up. However with fines that quickly accumulate to millions of dollars for Medicare Advantage plans, the directories will be seen as cost centers that can be sources of tight control and loss minimization through accuracy. It becomes a much easier internal bureaucratic argument for the directory team to get five more full time workers to chase directory data if the alternative analysis shows that 15% of the directory is known to be wrong and another 10% is suspected to be a mess.
Before, that argument had to focus on customer service and executive anal retentiveness. Now the argument is customer service and real money.
The second difference these fines will make is it will change what type of error insurers are willing to make on their directories.
most insurers are making a decision (given my experience, an unconscious decision) to have errors that cast the illusion of a much broader network. Right now the cost of errors going in that direction are mostly borne by members and not the insurance company unless the state has aggressive regulators with strong tools to do their job….
The Maryland study does show an interesting possibility of a counter-example. There a decision was made to show an accurate network and potentially under-report the network. Errors would be errors of omitting participating providers instead of errors of including non-participating providers. Members would be very confident that if they picked up the phone, they would be talking to a provider that could help them. In the other cases, it was a crap shoot if the provider that they reached was actually able to help them. There may have been providers in the network but out of the directory…
Networks will appear smaller, but the odds of making a call and being able to reach someone who can help should increase significantly over the next couple of months.
MazeDancer
This seems like an actual consumer benefit. Thus, good news for consumers and good news that more people will get jobs. Difficult jobs, but, theoretically, ones with, at least, decent health insurance.
piratedan7
bang for buck theory, if we hold the clinicians and the hospital as accountable for their decision making and treatment as we do… it stands to reason that the data that they have to work from also be that exacting when it comes to compensation and categorization.
Working on the software side of things, we strive for zero mistakes (despite being humans and all of that) so that nurses and docs have the best information at hand to make informed decisions because we know that if it was our Mom or child, we want it to be accurate. Shame that same sense of urgency doesn’t get translated into the financial side of affairs when it comes to health care.
MomSense
More accurate directories should be very helpful to consumers. Now the insurance companies will have incentive to push the providers to be more accurate, too. It seems like the providers don’t care if the directories are off as long as they are paid.
WereBear
Trying to figure out if a certain provider is in network can be a nightmare.
Richard Mayhew
@MomSense: Yep, speaking as a former directory nerd, the only data I could guarantee as accurate was anything that was tied to giving the providers money. They would scream if they were not paid on time and in full, so the data was always good. Now they weren’t paid differently if they were listed as a Hand surgeon or a General Orthopedic Surgeon, so who knows how any one doc was listed who did hand surgery as 90% of their practice.
Another North Carolinian
Finally decided the ACA is here to stay, jettisoned my increasingly exorbitant grandfathered policy, picked a doctor from those the Healthcare.gov’s directory listed as “accepting new patients,” went there to set up my patient profile and make an initial appointment. No, he is not taking new patients, but his two nurse practicioners are. I suppose “the practice” is taking new patients, but it still feels bait and switchy. With no known health issues, I can still shop around for another GP. Or I can just say, OK, it’ll do. When things seem to be going too well, they probably are.
japa21
There are two keys to maintaining accurate directories.
First of all, it is incumbent upon the provider to provide accurate information to the insurance companies, specially when there are demographic changes.
Second is for accurate entry into the providers’ systems.
Unfortunately, in each case, the person either doing the providing or doing the entering are low on the income scale.
Another major problem is with the consolidation going on. A provider could, in an independent practice, be part of a network. However, if that practice gets gobbled up by a system that isn’t in the network, the provider is no longer in the network and may not even be aware of it. Neither the system nor the provider informs the carrier.
A fourth problem is that many companies, including Mayhew Insurance and Japa Insurance, have several different networks dependent upon which products are being offered. A provider may be in the basic PPO offered by Japa Insurance but not in the Exchange product or the Medicare Advantage product. However, when a patient calls, all they generally will ask is if the provider accepts Japa Insurance and are usually told “Yes, we are in that network.” But for that patient’s policy they are not in network.
Resolving these problems will take extra efforts on both the provider and insurance side.
1. Insurance companies will have to do more frequent verifications of provider demographics, TINs, etc. Currently, that is done, at best, every 3 years.
2. Providers will have to be more diligent in providing insurance companies with any demographic or organizational changes.
3. Provider offices will have to be more diligent in confirming what type of policy a patient has before saying they are in or out of network.
Ultimately, it will come down to training and making the actual workers more invested in what they are doing (better pay helps).
The insurance companies now have a pretty good motivation. What motivation can be used on the provider side?
jay s
Do the new rules penalize under reporting your network as well as over reporting? The summary only talks about errors, I would assume under reporting would tend to self correct and wouldn’t require penalties.
Richard Mayhew
@jay s: If I am reading the rules right, underreporting is not a sanctionable event as long as it is in good faith. Now if a network has a sufficient number of endocrinologists (who treat diabetics) to pass regulatory standards and credentialing standards from NCQA, but 90% of the endocrinologists who have a signed contract to be in the network are not displaying, then this is an adverse selection problem of making the network ugly.
jay s
@Richard Mayhew: Hiding doctors to fool the invisible hand into smacking people in the face is something I would never have guessed.
MinbariSafari
As someone employed as a receptionist in a psychiatric practice, I couldn’t be happier with this news. I can’t tell you how many times a week I have callers arguing with me because some nebulous “someone” told them we were in their network. In some cases, we’ve NEVER (in 15 years!) been part of that network; in others, we were at one time, but dropped out anywhere from 5 to 10 years ago. Of course, this still leaves the problem of patients whose main insurance is with one carrier (like Blue Cross,where we’re in-network), but whose mental health benefits are with another carrier (like United HealthCare, where we’re out of network)…..and no one has bothered to explain that detail to them when they start looking for mental health providers….
KithKanan
@jay s: @Richard Mayhew: Shouldn’t this be solvable by only allowing doctors displaying in the directory to count for those regulatory standards (to discourage underreporting) while penalizing directory overreporting as described in the OP?
Richard Mayhew
@KithKanan: the guidelines St the federal level are so loose it would not matter. I have a post on the regulations shortly