Trudy Lieberman | Rural Health News Service
The other day came a lengthy https://www.cms.gov/Medicare/Health-Plans/ManagedCareMarketing/Downloads/Provider_Directory_Review_Industry_Report_Round_3_11-28-2018.pdf report from the Centers for Medicare & Medicaid Services (CMS) announcing worrisome findings for anyone with a Medicare Advantage plan and anyone thinking about buying one in the future. The findings are also relevant to anyone buying any kind of health insurance this year.
The ominous takeaway? The information given to consumers in the provider directories is deeply flawed, often misleading, inaccurate, and says CMS, “can create a barrier to care.” Imagine choosing a plan based on the information that your doctor is in the plan’s network only to find he or she is not, and you have to find a new doctor, perhaps in an inconvenient location.
Actually, finding any provider at all may be hard. CMS said that listed providers were not located at one-third of the locations indicated in the provider directories. That meant if a beneficiary tried to make an appointment with the doctor at a particular location, they’d be out of luck. Government researchers noted that sometimes providers did not work or accept the health plan at any of the locations listed in the directory.
Had the provider ever been part of the health plan’s network? Good question! CMS said this was a “concern.”
About half of the online directories the agency sampled had at least one inaccuracy. They included incorrect phone numbers, indications that a provider was accepting new patients when that wasn’t the case, and claims that providers were practicing at locations where they were not.
All these findings, of course, raise the question: Why so many mistakes given how detrimental this bad information can be to seniors? CMS investigated that, too, and found a “general lack of internal audit and testing of directory accuracy among many Medicare Advantage organizations.” The health plans apparently rely on credentialing services and vendor support to ensure directory adequacy, not exactly a reliable method, the agency concluded.
What’s worse is that when CMS researchers called doctors’ offices, they found directory information had been out of date for a long time, and some of the doctors listed in the networks had been retired or dead for years.
Medicare Advantage members aren’t the only ones facing the dilemma of inaccurate directories complicating their choices for the coming year. The consulting firm Avalere Health just reported that 72 percent of the plans offered on HealthCare.gov, the Affordable Care Act shopping exchange, are what’s called narrow network plans. “This is a trend we’re seeing not just in this market but in traditional employer-sponsored insurance, and this is going to continue,” says Chris Sloan, a director at Avalere. Such narrow network plans often provide no coverage for visits to doctors or hospitals that are not part of the network. That means you pay out of pocket if you use one of those providers.
Consumers are not only being hit with fewer choices and narrow networks but the information about providers may be as inaccurate for shoppers as it is for Medicare beneficiaries.
Narrow networks are a way to control costs because the insurer covers only those practitioners it’s able to reach a financial agreement with. In other words, the insurer wants lower prices, and the providers want higher ones. The two sides negotiate until they arrive at a price for a service that both parties find acceptable. Each side plays a lot of games, and the final contracts are not available for public inspection.
We keep hearing that continuity of care is important, and patients in the U.S. have always valued choosing their own physicians. Remember, maintaining that choice was a big selling point for the Affordable Care Act. But rhetoric that sells legislation is not the same as actual practice.
On the other hand, fewer choices are “not necessarily a negative thing so long as consumers understand what they are buying,” Sloan says.
But even that may be hard if the CMS revelations about Medicare Advantage plans are any guide.
What’s been your experience with directories from Medicare Advantage plans? Write to Trudy at firstname.lastname@example.org.■